case study congestive heart failure nursing

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This case study involves a 76 year old female named Mary Lou Poppins, who presented to the ED accompanied by her son. She called her son after having symptoms of shortness of breath and confusion. Her past medical history includes hypertension, hyperlipidemia, coronary artery disease, and she was an everyday smoker for 30 years. She reports her home medications are lisinopril, simvastatin, and baby aspirin. Her current lifestyle includes: being a widow of six years, she lives alone, she walks her dog everyday, she drives to her knitting group three days a week, she makes dinner for her grandchildren once a week, she attempts to eat healthy but admits to consuming salty and high fat foods, and she insists on being very independent.

Mary Lou Poppins initial vitals in the emergency department includes a blood pressure of 138/70, heart rate of 108. respiratory rate of 26, temperature 98.9 degrees fahrenheit, and oxygen saturation of 84%. Her initial assessment included alert and oriented to person and place, dyspnea, inspiratory crackles in bilateral lungs, and a cough with pink frothy sputum. Her labs and diagnostics resulted in a BNP of 740 pg/ml, an echocardiogram showing an ejection fraction of 35%, an ECG that read sinus tachycardia, and a chest x-ray that confirmed pulmonary edema.

The Emergency Department physician diagnosed Mary Lou Poppins with left-sided heart failure. The orders included: supplemental oxygen titrated to keep saturation >93%, furosemide IV, enoxaparin subq, and metoprolol PO. Nursing Interventions included: monitoring oxygen saturation, adjusting oxygen route and dosage according to orders, assessing mentation and confusion, obtaining IV access, reassessing vitals, administering medications, and keeping the head of the bed elevated greater than 45 degrees. She was admitted to the telemetry unit for further stabilization, fluid balance monitoring, and oxygen monitoring.

On day one of hospital admission, Mary Lou Poppins required 4L of oxygen via nasal cannula in order to maintain the goal saturation of >93%. Upon assessment, it was determined that she was oriented to person and place. Auscultation of the lungs revealed bilateral crackles throughout, requiring collaboration with respiratory therapy once in the morning, and once in the afternoon. Physical therapy worked with the patient, but she was only able to ambulate for 100 feet. During ambulation, the patient had a decrease of oxygen saturation and dyspnea, requiring her oxygen to be increased to 6L. At the end of the day, strict intake and output monitoring showed an intake of 1200 mL of fluids, with an urinary output of 2L.

On day two of admission, Mary Lou began demonstrating signs of improvement. She only required 2 L of oxygen via nasal cannula with diminished crackles heard upon auscultation. Morning weight showed a weight loss of 1.3 lbs and the patient was oriented to person, place, and sequence of events. During physical therapy, she was able to ambulate 300 feet without required increased oxygen support. Daily fluid intake was 1400 mL with a urinary output of 1900 mL.

On the third and final day of admission, Mary Lou was AOx4 and did not require any type of oxygen support. When physical therapy arrived, the patient was able to ambulate 500 feet, which was close to her pre-hospital status. When the doctor arrived, the patient informed him that she felt so much better and felt confident going home. The doctor placed orders for discharge.

Upon discharge and throughout the patient’s hospital stay, Mary Lou Poppins was educated regarding the disease process of heart failure; symptoms to monitor for and report to her doctor; the importance of daily monitoring of weight, blood pressure, and heart rate; and the importance of adhering to a diet and exercise regime. Education was also provided regarding her medications and the importance of strictly adhering to them in order to prevent exacerbations of heart failure. Smoking cessation was also included in her plan of care. The patient received an informational packet regarding her treatment plan, symptoms to monitor for, and when to call her physician. Upon discharge, the patient was instructed to schedule a follow up appointment with her cardiologist for continued management of her care.

The patient was put in contact with a home health agency to help manage her care. The home health nurse will help to reinforce the information provided to the patient, assess the patient’s home and modify it to meet her physical limitations, and help to create a plan to meet daily dietary and exercise requirements. Regular follow-up appointments were stressed to Mary Lou Poppins in order to assess the progression of her disease. It will be important to monitor her lab values to also assess her disease progression and for any potential side effects associated with her medications. Repeat echocardiograms will be necessary to monitor her ejection fraction; if it does not improve with the treatment plan, an implanted cardiac defibrillator may be necessary to prevent cardiac death.

Open-Ended Questions

• What were the clinical manifestations that Mary Lou Poppins presented with in the ED that suggested the new onset of CHF?
• What factors most likely contributed to the onset of CHF?
• What patient education should Mary Lou Poppins receive on discharge in regards to managing her CHF?

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Congestive Heart Failure (CHF) Nursing Diagnosis and Care Plan

Last updated on February 20th, 2023 at 08:45 am

CHF can affect either both sides of the heart or just one side. The three types of CHF are biventricular, left-sided, and right-sided heart failure. In left-sided heart failure, the left ventricle becomes enlarged (hypertrophy) and becomes dilated together with the left atrium in order to compensate for the increased pressure.

In time, the cardiac muscles of the right chambers wear down, causing right-sided heart failure. Failure of both sides of the heart is called biventricular heart failure.

Signs and Symptoms of Heart Failure

Causes of heart failure, complications of heart failure, diagnostic tests for heart failure, treatment for heart failure.

2. Surgical interventions. These include coronary bypass surgery, heart valve repair or replacement, and heart transplant. It may also involve the insertion of medical devices such as implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy (CRT), and ventricular assist devices (VADs).

CHF Nursing Diagnosis

Chf nursing care plan 1.

Desired outcome: The patient will be able to maintain adequate cardiac output.

CHF Nursing Care Plan 2

CHF Nursing Care Plan 3

Nursing Diagnosis: Deficient Knowledge related to new diagnosis of Congestive Heart Failure as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”

CHF Nursing Care Plan 4

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

CHF Nursing Care Plan 5

CHF Nursing Care Plan 6

Nursing Diagnosis: Acute Pain related to decreased myocardial blood flow as evidenced by  pain score of 10 out of 10, verbalization of pressure-like/ squeezing chest pain (angina), guarding sign on the chest, blood pressure level of 180/90, respiratory rate of 29 cpm, and restlessness

CHF Nursing Care Plan 7

Desired Outcome: The patient will achieve effective breathing pattern as evidenced by normal respiratory rate, oxygen saturation within target range, and verbalize ease of breathing.

Nursing References

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

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Congestive heart failure

An 'f' isn't an option.

Markaity, Michael RN, PCCN

Staff Nurse

Spectrum Health Butterworth • Grand Rapids, Mich.

The author and planners have disclosed that they have no financial relationships related to this article.

Congestive heart failure (CHF) is one of the fastest growing diagnoses in the world today. Five million individuals worldwide have CHF, and over 400,000 new cases will be diagnosed this year. We provide you with the tools to help your patients keep their CHF under control .

Mr. R, a 55-year-old Black man, comes to the ED with a complaint of being “winded.” He states that over the past 2 weeks, he has noted worsening dyspnea on exertion. Although in the past he has been able to walk a 3-mile route easily, today he couldn't walk even 1 mile without stopping for frequent rests. His vital signs show a temperature of 98.6° F (37° C); heart rate, 102 beats/minute; respiratory rate, 20 breaths/minute, and BP, 158/96 mm Hg. His pulse oximetry reading is 93% but after going to the restroom, it's noted to be 86% with an increase in respirations to 26 breaths/minute. A physical exam reveals moist crackles halfway up bilaterally, and an S 3 heart sound along with a murmur. Mr. R has also noted a persistent increasing cough. His lab work is notable for a brain natriuretic peptide (BNP) level of 842 pg/mL.

Ms. T is a 74-year-old White woman who's next door to Mr. R. She was sent to the ED by her physician after an office visit showed a weight gain of 20 lb over the last month. She has a history of smoking and pulmonary hypertension. She complains that it's harder for her to bend over and tie her shoes, and she has also noticed that her shoes are tighter on her feet. Her vital signs and lab work are normal, with the exception of a BNP level of 1,290 pg/mL. Her physical exam reveals bilateral jugular venous distension and some abdominal distension. There's also 2+ pitting edema in her lower extremities, as well as in her feet and ankles. Her lungs, however, are clear.

Both Mr. R and Ms. T have CHF, one of the fastest growing diagnoses in the world today. Over 5 million individuals worldwide have a diagnosis of CHF. As this diagnosis becomes more prevalent, over 400,000 new cases will be seen every year. Twenty percent of these patients will die in the first year, and 50% will die within a 5-year period. CHF accounts for 5% to 10% of total hospital admissions, and over $38 billion is spent annually to treat this disease, according to the Family Practice Network.

Although it affects individuals of all races, Blacks are more prone to the disease, followed by Hispanics, then Whites. Comorbidities play a huge role in both the onset and treatment of CHF. These include, but are not limited to, pulmonary hypertension, coronary artery disease (CAD), and diabetes. Access to, and the availability of, quality medical care can't be underestimated.

The following article will define CHF and provide an overview of its two types and their subclassifications, discuss signs and symptoms, and review current treatment options and modalities.

A weak pump

To the public, CHF may often be thought of in terms of a “heart attack” or cardiac arrest. In fact, CHF is the inability of the heart to adequately pump blood throughout the body (see How it happens ).

Carbon dioxide (CO 2 )–laden blood returns to the heart from both the superior vena cava and the inferior vena cava. It empties into the right atrium and is pumped through the tricuspid valve into the right ventricle. Via the pulmonary artery, the blood is sent to the lungs, where CO 2 and oxygen (O 2 ) are exchanged. The reoxygenated blood is then brought to the left atrium by the pulmonary veins and deposited into the left atrium. It's then pumped through the mitral valve into the left ventricle, from which it moves through the aortic valve into the aorta and to the body (see Inside a normal heart ). In CHF, this process is faulty.

Left-sided CHF

In left-sided CHF, blood and fluid back up into the lungs. The root cause of this is the left ventricle's inability to propel the blood forward. There are several factors that can lead to this condition; CAD is the most common. A lack of O 2 -carrying blood to the myocardial muscle leads to ischemia. If untreated, the ischemic area dies. The end result is weakened or dead heart muscle, which limits the ventricle's contracting ability.

Uncontrolled hypertension is a leading cause of CHF. Whether primary (no known cause) or secondary (underlying causes such as too much salt and/or fluid in the body, chronic kidney disease, diabetes, and heart valve issues, to name a few), hypertension leads to CHF due to an overstretching of the myocardial fibers in the ventricle. Cardiomyopathy, in which the ventricular muscle becomes enlarged, thickened, or rigid, can contribute to CHF via the same mechanism. As with hypertension, the cause of cardiomyopathy can be either idiopathic (unknown) or a result of alcohol/drug misuse, heart/valve disease, hypertension, or a viral disease affecting the heart.

Heart dysrhythmias may also be the culprit. Atrial fibrillation and atrial flutter cause the atrium to contract suboptimally. This results in the loss of atrial kick, in which up to 30% of the atrium's volume doesn't get to the ventricles and isn't pumped out to the lungs and/or the aorta. Bradycardic rhythms, whether electrical/physiologic (sinus bradycardia, junctional, and AV blocks) or pharmacologic (digoxin, beta-blockers, and calcium-channel blockers in particular) in nature, are also suspects.

Subclassifications

Left-sided CHF can further be broken down into two subdivisions: systolic and diastolic. Recall that in systole, the ventricles are contracting, which forces the blood forward into the system. In systolic CHF, the problem begins when the left ventricle undergoes an insult and both the cardiac output (CO) and BP decrease. Then neurohormonal activation occurs, including stimulation of the sympathetic nervous system, the renin-angiotensin-aldosterone-system, and the arginine vasopressin system. These mechanisms are all designed to increase both CO and BP. They do so, however, at the cost of increasing the amount of fluid in the bloodstream and the heart rate.

The Frank-Starling law shows that stroke volume increases with an increase of blood filling the heart, known as the end-diastolic filling volume. Over time, this leads to an “overstretched rubber band” syndrome in which the rubber band loses its “snap.” The ventricle is unable to eject blood efficiently out to the aorta as it becomes overstretched. This leads to apoptosis, or programmed cell death, within the ventricle, as well as an actual remodeling of the ventricular shape itself. The end result is a decrease in blood ejected from the ventricle.

Diastole is the resting or relaxation phase of the cardiac cycle. In systolic CHF, the heart is unable to adequately pump blood out into the body. Diastolic CHF is the inability of the heart to properly refill after systole. This can be due to a “stiffer” ventricular wall, which then results in a lowered stroke volume and a decrease in CO. Less CO means less O 2 and nutrients to the body. Diastolic CHF has the same causes as systolic CHF.

The symptoms of left-sided CHF are primarily pulmonary in nature. The backup of blood into the lungs results in increased hydrostatic pressures in the alveoli, which forces fluid into the alveolar sacs and prevents O 2 /CO 2 exchange. In extreme circumstances, this can lead to pink, frothy foam when the patient coughs. Other symptoms include orthopnea (shortness of breath when the patient is lying down) and paroxysmal nocturnal dyspnea (PND). Orthopnea is relieved by having the patient stand or sit up. The patient may complain of having to sleep with two or more pillows or sitting up in a chair. PND is the sensation of shortness of breath that suddenly awakens the patient in the night, often after 1 to 2 hours of sleep. Wheezing may also be noted. In some cases of mild diastolic CHF, the lung sounds may be normal.

The stethoscope is an important tool in evaluating left-sided CHF. S 1 and S 2 are the normal heart sounds that give the classic “lub-dub.” Two unique heart sounds may also be auscultated. Heard after the second heart sound, an S 3 (sometimes called an S 3 gallop) is best heard over the apex of the heart using the bell of the stethoscope. Also known as the third heart sound, it may be likened to the word “Kentucky” with the “y” being the S 3 . Although not uncommon in younger individuals, an S 3 can be indicative of a “floppy” ventricle seen in left-sided CHF. The S 3 is the result of vibrations in the ventricular walls, resulting from the first rapid filling. (See “Heart Sounds: Hear the Story” on page 51.)

In the continuum of CHF, the ventricle can become stiffer. This is an end result of the enlarged ventricle and the aforementioned remodeling. As the ventricle becomes stiffer, the left atrium is forced to work harder to move blood into the left ventricle. The fourth heart sound, S 4 , is heard during the second phase of ventricular filling just before S 1 . This results from the vibrations of the valves and ventricular walls as blood is forced into the ventricle. The sound is like that of the word “Tennessee,” with the “Ten” being the fourth sound. It, too, is best heard over the apex of the heart using the bell of the stethoscope.

Murmurs are indicators of faulty valves. Whether systolic or diastolic, their presence can give further credence to a diagnosis of CHF. Leaky valves can be the cause of retrograde blood flow, either by themselves or in conjunction with ventricular incompetence. Stenotic valve, which is a narrowing within the value itself, can cause hypertrophy of the ventricle.

Auscultation of the lungs can detect adventitious breath sounds associated with CHF. Crackles are indicative of fluid buildup in the small airways, resulting from increased pressure in the alveoli. They can be heard on both inspiration and expiration. Crackles are described as being fine, medium, or coarse. The location of the crackles should always be included in discussions with the healthcare provider. Wheezes can be heard in patients with CHF. Also known as “cardiac asthma,” this is the result of fluid buildup in the smaller airways of the lungs. Wheezes can be heard on inspiration and expiration. The presence of wheezes from a cardiac origin is an indication of worsening CHF because the wheezing results from increasing fluid in the lungs.

Right-sided CHF

Conversely, right-sided CHF exhibits little or no pulmonary involvement. Think of it this way: left CHF = lungs; right CHF = rest of the body. The definition—the inability of the heart to adequately pump—is the same. In this case, however, the blood backs up into the body. Right-sided CHF is a result of increased pressure in the lungs. Because the lung pressures are lower than the aorta, the right ventricle doesn't need to pump as hard as the left. Conditions such as pulmonary hypertension, chronic obstructive pulmonary disease, pulmonic valve stenosis, and chronic blood clots can lead to an enlargement of the right ventricle. The backup of fluid systemically leads to engorgement of the jugular veins and swelling in the abdomen/sacrum, lower legs, and feet.

Jugular venous distension is reflective of the retrograde flow seen in elevated right atrial pressures. The blood backs up through the superior vena cava into the jugular vein. With the patient lying at a less than 45-degree angle, the distended vein can be seen best over the sternocleidomastoid muscle.

Hepatomegaly, or liver enlargement, isn't in itself a disease, but rather a sign of one. In CHF, this is due to the backup of blood from the inferior vena cava to the portal blood system. An enlarged liver won't be seen, but may be felt by palpating the right upper abdominal quadrant just under the ribs as the patient takes in and lets out a deep breath. Ascites is excess fluid found in the peritoneal cavity. This, too, is a result of backflow through the inferior vena cava. It may or may not be associated with hepatomegaly. In bedridden patients, this excess fluid may also be seen pooling in the sacral area.

Edema is swelling, which can be observed from fluid accumulation in body tissue. It's most commonly seen in the feet, ankles, and legs. Edema can be divided into two categories: pitting and nonpitting. Nonpitting edema usually affects the legs and arms. Pressing on the affected area won't leave any trace behind. In contrast, pitting edema will leave a pit or dent in the skin. A grading scale of +1 to +4 is used. In general, +1 is mild, +2 is moderate, +3 is deep, and +4 is very deep pitting.

A touch of class

There are two organizations that have classifications for CHF. The American College of Cardiology (ACC)/American Heart Association (AHA) classifies CHF as:

• High risk of developing heart failure : This includes hypertension, diabetes, CAD, and family history of cardiomyopathy.
• Asymptomatic heart failure : Candidates for this level are those with a previous history of myocardial infarction (MI), left ventricular dysfunction, and valvular heart disease.
• Symptomatic heart failure : These are patients with structural heart failure, dyspnea and fatigue, and impaired exercise tolerance.
• Refractory end-stage heart failure : These individuals have marked symptoms at rest despite maximal medical therapy.

Similarly, the New York Heart Association heart failure classification also has four classes:

• Class I (mild) : No limitation of physical activity; ordinary physical activity doesn't cause tiredness, heart palpitations, or shortness of breath.
• Class II (mild) : Slight limitation of physical activity; the patient is comfortable at rest, but ordinary activity causes tiredness, heart palpitations, and/or shortness of breath.
• Class III (moderate) : Marked limitations of physical activity; the patient is comfortable at rest, but less than ordinary physical activity causes tiredness, heart palpitations, or shortness of breath.
• Class IV (severe) : Severe limitation of physical activity; the patient is unable to carry out any physical activity without discomfort. Symptoms are present at rest, and any physical activity increases that discomfort.

Diagnostic methods

A diagnosis of CHF is obtained by utilizing several methods. Blood is drawn to pinpoint the BNP level. As the ventricles become overstretched, BNP is released into the bloodstream. Levels of less than 100 png/mL are generally considered negative for CHF. At 100 to 300 png/mL, CHF is considered to be present. As the levels increase above 300 png/mL, the degree of CHF worsens. A similar lab test is for N- terminal-pro-BNP (NT-pro BNP). NT-proBNP levels rise in proportion to the severity of CHF. Unlike BNP, it has been shown to be influenced by both the age and sex of the patient. Be aware of the type and parameters of BNP being used by the reporting lab to ascertain the meaning of the results.

Chest X-rays will be ordered to verify if there's any fluid in the lungs. They can also be used to determine if the heart is enlarged. An echocardiogram will also be ordered to visualize the walls of the heart as they contract, as well as the competence of the heart valves. An echocardiogram also measured the ventricle's ejection fraction (EF)—the percentage of blood ejected by the ventricle during systole. A normal EF is between 50% and 70%. A percentage of 40% to 50% may indicate some damage in the heart. An EF below 40% may indicate either CHF or cardiomyopathy.

Cardiac catheterization may also be helpful. Catheterizing the left side of the heart can be used to determine if there are any occlusions that may be causing the myocardium to become ischemic. Catheterizing the right side of the heart can be used to examine the fluid status and pressures within the heart to determine if right-sided CHF is present.

Managing CHF

Treatment for CHF begins with lifestyle modifications. If the patient smokes, he or she should be encouraged to stop. Exercise should be encouraged if not contraindicated. Dietary modifications and fluid intake restrictions should be utilized.

Medications and procedures

The proper medications are an important component of CHF treatment. They include inotropic agents, both oral and I.V., to improve the contraction strength of the ventricles, resulting in improved CO. Beta-blockers slow the heart rate and lower BP, lessening the strain on the heart that comes from sympathetic nervous system stimulation. In fact, studies have linked certain beta-blockers to the suppression of apoptosis and stabilization of the mitochondrial walls in the epithelial cells.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are also key medications for CHF. Whether inhibiting the conversion of angiotensin I to angiotensin II (ACE inhibitors) or blocking the angiotensin II receptors in the blood vessels (ARBs), the end result is the same. The blood vessels in the body are dilated, which reduces BP and decreases afterload of the ventricles. ACE inhibitors can sometimes lead to a chronic cough, which is one reason why ARBs may be prescribed instead. Along the same lines, human B-type natriuretic peptides can be used I.V. to dilate the blood vessels. Care should be taken when assessing BNP levels because this medication is actually synthetic BNP, which will falsely elevate the BNP level.

Diuretics play a major role in CHF treatment. Diuretics act within the kidney to promote increased urination. The use of these medications can cause impressive urinary amounts and drastic weight loss in the first few days of therapy. One liter of urine output is equal to 1 kg of weight lost. Examples of diuretics include loop diuretics, thiazides, and carbonic anhydrase inhibitors. These medications may cause depleted potassium, a critical electrolyte within the body. In such cases, potassium-sparing diuretics may be ordered. These are broken down into two classes: aldosterone antagonists and epithelial sodium channel blockers. Regardless of the type of diuretic used, lab values such as blood urea nitrogen, creatinine, sodium, and potassium should be monitored closely.

Precisely because the kidney can become overstressed during diuresis, a procedure called aquapheresis was developed. Using the same principle as dialysis, aquapheresis (or ultrafiltration) uses a catheter to remove excess fluid from the body. The blood is then returned to the body via another catheter. This process can remove up to 500 mL or 1.1 kg of water weight per hour without the use of diuretics. This can be done as an outpatient (for 3 days/week) or as an inpatient (for 24 to 36 hours).

Patients who have either atrial fibrillation or atrial flutter may be candidates for cardioversion or ablation. Cardioversion is the delivery of an electric shock to the heart that attempts to reset the heartbeat to sinus rhythm. Ablation calls for a special device that delivers energy to the area of the heart or conduction system that's responsible for the arrhythmia.

Devices and surgery

Medical device implantation is another option. Electrically induced bradycardia patients may benefit from a pacemaker. Healthcare providers of patients at risk for lethal arrhythmias as a result of severe left ventricular failure or cardiomyopathy may suggest placing an implantable cardioverter defibrillator (ICD). In addition to functioning as a pacemaker, ICDs are able to perform antitachycardia pacing and internal cardioversion/defibrillation in the presence of lethal ventricular dysrhythmias.

CHF can lead to asynchronous contractions between the right and left ventricles. In these patients, this leads to an even greater decrease in CO. Cardiac resynchronization therapy, also known as biventricular pacing, can be beneficial. This leads to a more harmonious relationship between the ventricles, improving both CO and EF.

Another type of medical device is the ventricular assist device (VAD). This can be implanted in either ventricle and helps pump blood out into the body. VADs can be used as a bridge to a heart transplant or as the functioning part of the heart if the patient isn't a transplant candidate.

Surgery may also be an option. Valve replacement/repair may be justified in the presence of incompetent or stenotic valves. Coronary bypass surgery may be an option if it's felt that the myocardium may benefit from revascularization. Heart transplantation can also be considered.

In the very last stages of CHF, palliative care and/or hospice might be utilized. Palliative care allows the patient options to remain comfortable for as long as possible. Hospice is able to help patients and their families as they transition through end-of-life care and, for the families, the aftermath of losing their loved one.

Patient teaching pearls

After diagnosis, CHF is often a lifelong process. Patients, as well as their families, must be educated on not only the disease process, but also the modifications and lifestyle changes that they'll experience. This education should be initiated in the healthcare provider's office or in the hospital if the patient is admitted. A brief description of the heart and its function should be given, as well as a simple, yet clear, definition of CHF. The patient/family should be made aware of the causes and symptoms associated with CHF. The medications that have been prescribed should be reviewed, as well as their functions and adverse reactions. Of course, plenty of time should be available to allow patients and their families to ask questions.

The Joint Commission has set up specific discharge guidelines for post-hospitalization CHF patients. Evaluation of left ventricular systolic function must be performed. Adult smoking cessation advice/counseling needs to be addressed. Discharge instructions must be given to each patient, including the prescription of either an ACE inhibitor or ARB medication or the documented reasons for not doing so.

Discharge instructions should be clear and concise. Beta-blockers should be strongly considered in conjunction with the ACE inhibitor/ARB. Patients should be instru cted on proper diet and fluid parameters. Patients are placed on a fluid restriction of no more than 2 L of fluid/day. One suggestion to help patients get used to this restriction might be to fill up an empty 2 L soda bottle with water in the morning. Whenever fluid is to be consumed, first pour an equal amount of the water into the drinking container, empty it, and then fill it with the beverage. In this manner, patients and their families will have a clear idea of how much fluid is left for the day.

Patients should also be encouraged to follow a low-sodium diet, typically totaling no more than 2 g of sodium/day. Sample menus can be sent home with the patient, although a good rule of thumb is eliminating table salt. Salt leads to fluid retention, which can lead to increased BP and more stress on the heart. Using herbal seasonings rather than salt substitute may be beneficial. Salt substitute is often potassium chloride, so the potential for hyperkalemia is present. Patients and their families should be encouraged to become label readers to eliminate as much sodium from the diet as possible.

If hospitalized, the patient should expect to be weighed every morning. This practice should be continued at home. Patients should be alert for any changes in weight and record them in a daily log. A weight gain of 1 to 2 lb/day or 4 to 5 lb/week may be indicative of increasing fluid retention. If this occurs, the patient should alert his or her healthcare provider or outpatient clinic for instructions. The patient may then be instructed to take extra doses of the diuretic, if prescribed, to prevent further retention, as well as dealing with the current overload.

Lastly, patients should follow up with their healthcare provider, whether a primary care provider, cardiologist, or CHF clinic. In doing so, both patients and their healthcare providers can keep tabs on progress made, as well as keeping alert for any potential problems. Hospital readmission for CHF is high: 24.7% in the first 30 days, 27% in the first 6 months, and 35% within the first year. (See the online exclusive “Heart Failure Readmissions: Can Hospital Care Make a Difference?” at http://www.NursingMadeIncrediblyEasy.com .)

Teamwork for success

CHF is a complex disease and a lifelong process requiring diligence and discipline. It isn't unusual for a CHF patient to be seen in the ED after eating a piece of pizza. Patients may need hospitalization if they run out of their medication for a few days. Patient involvement, education, and outpatient care are key principles in managing CHF outside the hospital. Prompt diagnosis and timely interventions are core inpatient tactics. The alliance between the patient and healthcare provider outside the hospital, and the patient, nurse, and healthcare provider during admissions, must be strong to facilitate proper care of the CHF patient.

S3: Classic sign of heart failure

S 3 , also known as ventricular gallop , is commonly heard in children and may be normal in patients during the last trimester of pregnancy; however, it may be a cardinal sign of heart failure in other adults. Because it follows S 2 , it's commonly compared to the «y« sound in «Ken-tuck-y.« S 3 is low-pitched; you'll hear it best at the apex when the patient is lying on his left side.

• In early ventricular diastole, the pulmonic and aortic valves snap closed, producing S 2 .
• A large amount of blood rushes into the ventricles, possibly as a result of pulmonary edema, an atrial septal defect, or an acute MI.
• The rapid ventricular filling causes vibrations, producing S3.

S4: An MI aftereffect

Also called an atrial gallop , S 4 is an adventitious heart sound that you'll hear best over the tricuspid or mitral area when the patient lies on his left side. Patients who are elderly and those with hypertension, aortic stenosis, or a history of MI may have an S 4 . It's commonly described as sounding like «Ten-nes-see« because it occurs just before S 1 , after atrial contraction.

• In atrial diastole, the atria contract to eject blood into the ventricles.
• If the ventricles don't move or expand as much as they should, the atria must work harder to eject the blood. This causes the atria to vibrate, producing a sound known as S 4 .
• As the ventricles fill and pressure rises, the mitral and tricuspid valves snap close, producing S 1 .

cheat sheet

Classifying chf.

The ACC/AHA classification

• High risk of developing heart failure : Hypertension, diabetes, CAD, family history of cardiomyopathy
• Asymptomatic heart failure : Previous history of MI, left ventricular dysfunction, valvular heart disease
• Symptomatic heart failure : Structural heart failure, dyspnea and fatigue, impaired exercise tolerance
• Refractory end-stage heart failure : Marked symptoms at rest despite maximal medical therapy

The New York Heart Association classification

• Class I (mild) : No limitation of physical activity; ordinary physical activity doesn't cause tiredness, heart palpitations, or shortness of breath
• Class II (mild) : Slight limitation of physical activity; the patient is comfortable at rest, but ordinary activity causes tiredness, heart palpitations, and/or shortness of breath
• Class III (moderate) : Marked limitations of physical activity; the patient is comfortable at rest, but less than ordinary physical activity causes tiredness, heart palpitations, or shortness of breath
• Class IV (severe) : Severe limitation of physical activity; the patient is unable to carry out any physical activity without discomfort; symptoms are present at rest, and any physical activity increases that discomfort

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3 Sample Nursing Care Plan for CHF [Congestive Heart Failure] (with rationales and case scenario)

Last updated on December 28th, 2023

Sample Nursing Care Plan for CHF [Congestive Heart Failure]

What is congestive heart failure.

Heart failure is a chronic, progressive condition. It occurs when the heart is unable to pump effectively and produce enough cardiac output to successfully perfuse the rest of the body’s tissues and organs. An individual can have right-sided or left-sided heart failure as well as systolic or diastolic heart failure.

Left-sided heart failure is also known as Congestive Heart Failure (CHF) . In CHF, the heart is either unable to contract completely or fill completely during relaxation. It can lead to an inadequate amount of blood pumping out of the heart. Thereby, backing up into the right side and then ultimately to the lungs and throughout the body causing congestion.

Systolic heart failure means the heart is not able to contract completely and affects its ability to pump blood out of the heart.

Diastolic heart failure means the heart is unable to relax fully between heartbeats and allows the appropriate amount of blood into the ventricle.

In this post, we’ll formulate a sample nursing care plan for a patient with Congestive Heart Failure (CHF) based on a hypothetical case scenario .

CHF Case Scenario

A 74-year old Hispanic male presents to the Emergency Department with complaints of increased dyspnea, reduced activity tolerance, ankle swelling, and weight gain in recent days. He has a known history of hypertension and heart failure. He reports over the past 3 days his shortness of breath, particularly with activity, has increased significantly.

He is also now using 3 pillows to sleep at night instead of his usual 1 pillow, and he has experienced a 10-pound weight gain in 3 days. He states he is now only able to ambulate 1 block before needing to stop and rest whereas in the past he could walk half a mile. 

The nurse notes dyspnea upon minimal excretion with position changes.  Upon physical assessment his breathing is shallow and labored, respiratory rate is 30 breaths per minute, heart rate 115 beats per minute, oxygen saturation 83% on room air, blood pressure 179/98 mm Hg, he has +4 pitting edema in bilateral lower extremities, and crackles are heard in his lung fields throughout.

The patient’s lab work reveals an elevated BNP level of 954pg/mL and a chest x-ray shows pulmonary congestion. The last echocardiogram in the patient’s chart (completed 3 months prior) showed an Ejection Fraction (EF) of 40%.

The patient is to be admitted to the hospital for Acute Exacerbation of Congestive Heart Failure (CHF) . 

Case Discussion

The main assessment findings the nurse should be aware of for this patient begin with his vital signs, all of which are listed are abnormal.

The patient has labored, tachypneic, breathing. He is also tachycardic and has a decreased oxygen saturation. This demonstrates to the nurse that the patient is not hemodynamically stable and the main goal is stabilizing the patient’s respiratory status. 

In addition, the nurse should also note the reported weight gain and visibly apparent edema. These assessment findings are able to help the nurse critically think and identify a potential list of differential diagnoses prior to lab and imaging results becoming available.

When assessing this patient, the nurse will want to remember ABCs (airway, breathing, circulation) of care.  The patient’s airway is protected and he is able to breathe on his own.

However, his breathing is compromised due to excessive fluid. Therefore, that becomes the priority for the patient and the nurse should begin by improving his oxygen saturation and breathing status.  

Once the patient’s breathing status is stabilized the next likely task will be to diuresis the patient.  In doing this, it will help to remove additional fluid thereby improving his oxygen and breathing capability further.

#1 Sample nursing care plan for CHF – Impaired gas exchange

Nursing assessment.

Subjective Data:

• Reported increased shortness of breath
• Using 3 pillows to sleep at night (increase from usual 1 pillow)
• Decreased activity level due to shortness of breath

Objective Data:

• Tachypneic, respiratory rate of 30 breaths/minute
• Crackles in lung fields
• Oxygen saturation 83% on room air
• Congestion on chest x-ray
• +4 pitting edema

Nursing Diagnosis [ Impaired gas exchange ]

Impaired gas exchange related to fluid overload as evidenced by labored, tachypneic breathing, decreased oxygen saturation, crackles in lung fields, pitting edema, congestion on chest x-ray.

Short-term goal

To increase oxygen saturation ≥92% prior to transfer from ED and admission to hospital floor unit

Nursing Interventions with Rationales

Long-term goal

To decrease excess fluid by 10 pounds by discharge to return patient to baseline dry weight

Expected Outcome

• This will reduce hypoxemia resulting in improved oxygen saturation and reduce dyspnea.
• Excess fluid will be removed and the patient’s weight will return to baseline.
• Reduced congestion will improve gas exchange.

#2 Sample nursing care plan for CHF – Decreased cardiac output

• Needs 3 pillows at night to sleep
• 10-pound weight gain
• Ankle swelling
• Tachycardia
• Hypertension
• Crackles in lung fields throughout
• Ejection fraction (EF) 40%
• Elevated BNP 954pg/mL
• Congestion seen on chest x-ray

Nursing Diagnosis [ Decreased cardiac output ]

Decreased cardiac output related to altered contractility as evidenced by tachycardia, hypertension, orthopnea, edema, abnormal lab work, and reduced EF.

To stabilize vital signs and maintain adequate oxygen saturation prior to transfer from ED to the hospital unit.

To improve cardiac contractility by discharge

• Maintain oxygen saturation above 92%
• Decrease in blood pressure to patient’s baseline (ideally <120/80)
• Improved contractility by decreasing excess fluid, improvement in breathing status, and stabilization of vital signs

#3 Sample nursing care plan for CHF – Decreased activity tolerance

• Only able to ambulate 1 block
• Reduced activity level
• Dyspnea on minimal exertion
• Tacypnea (RR 30 bpm)
• Tachycardia (PR 115 bpm)
• Decreased oxygen saturation (83% at room air)

Nursing Diagnosis [ Decreased activity tolerance ]

Decreased activity tolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea, tachypnea, tachycardia, decreased oxygen saturation, and fatigue.

To limit activity to decrease oxygen demand while also increasing oxygen supply

To increase activity level to patient’s baseline prior to discharge.

• Improved oxygenation status (≥92%)
• Patient’s activity level will return to baseline

It is vital to monitor patients admitted with congestive heart failure closely.  In particular, detailed and accurate intake and output records should be kept to show the progress and success of treatments being administered.

This will also help to determine if additional medications are warranted or dosage adjustments need to be made.

Close monitoring of types of food and drinks is also important. Because some food may cause patient to retain more fluid than others. Providing proper patient education is key for these patients to support them in understanding their condition and diagnosis.  

Likewise, education will help the patient to be aware of specific things to avoid at home in terms of food or drink and why these should be avoided.

Click here to see a full list of Nursing Diagnoses related to Congestive Heart Failure (CHF).

Congestive heart failure is a chronic condition that can progress over time. Acute exacerbations of this chronic condition can also be very common especially if an individual is not following or is unaware of the appropriate guidelines and recommendations.

It is important for nurses to understand the various symptoms a patient may present with when experiencing an acute exacerbation. It is also imperative that the nurse assesses the individual’s airway and breathing status immediately and prioritizes this above any other nursing intervention. 

Lastly, providing thorough patient education both verbally and in writing is essential for these individuals to help them understand their diagnosis and what measures they can take at home to prevent additional exacerbations.

Ackley, B.J., Ladwig, G.B., Flynn-Makic, M.B., Martinez-Kratz, M.R., & Zanotti, M. (2020). Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care [eBook edition]. Elsevier.

Comer, S. and Sagel, B. (1998). CRITICAL CARE NURSING CARE PLANS . Skidmore-Roth Publications.

Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing Care Plan: Guidelines for Individualizing Client Care Across the Lifespan [eBook edition]. F.A. Davis Company.

Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.

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13 Heart Failure Nursing Care Plans

Utilize this comprehensive nursing care plan and management guide to provide optimal care for patients with heart failure . Gain valuable insights on nursing assessment , interventions, goals, and nursing diagnosis specifically tailored for heart failure in this guide.

Table of Contents

What is heart failure, nursing problem priorities, nursing assessment, nursing diagnosis, nursing goals, 1. initiating interventions for decrease in cardiac output, 2. monitoring diagnostic procedures and laboratory studies, 3. administering medication and providing pharmacological interventions, 4. maintaining or improving respiratory function, 5. managing fluid volume and electrolyte imbalance, 6. providing perioperative nursing care, 7. managing acute pain and discomfort, 8. promoting adequate tissue perfusion and managing decreased cardiac tissue perfusion, 9. promoting optimal nutritional balance and adherence to low-sodium diet, 10. maintaining skin integrity & preventing pressure ulcers, 11. managing decreased tolerance to activity and fatigue, 12. reducing anxiety, fear and improving coping, 13. initiating health teaching and patient education, discharge and home care guidelines, discharge goals, documentation guidelines, recommended resources, references and sources.

Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which the heart cannot pump enough blood to meet the body’s metabolic needs following any structural or functional impairment of ventricular filling or ejection of blood.

Heart failure results from changes in the systolic or diastolic function of the left ventricle . The heart fails when, because of intrinsic disease or structural, it cannot handle a normal blood volume or, in the absence of disease, cannot tolerate a sudden expansion in blood volume. Heart failure is a progressive and chronic condition managed by significant lifestyle changes and adjunct medical therapy to improve quality of life. Heart failure is caused by various cardiovascular conditions such as chronic hypertension , coronary artery disease, and valvular disease.

Heart failure is not a disease itself. Instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion , and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.

Clinical Manifestations

Heart failure can affect the heart’s left side, right side, or both sides. Though, it usually affects the left side first. The signs and symptoms of heart failure are defined based on which ventricle is affected—left-sided heart failure causes a different set of manifestations than right-sided heart failure.

Left-Sided Heart Failure

• Dyspnea on exertion
• Pulmonary congestion, pulmonary crackles
• Cough that is initially dry and nonproductive
• Frothy sputum that is sometimes blood-tinged
• Inadequate tissue perfusion
• Weak, thready pulse
• Tachycardia
• Oliguria, nocturia

Right-Sided Heart Failure

• Congestion of the viscera and peripheral tissues
• Edema of the lower extremities
• Enlargement of the liver (hepatomegaly)
• Anorexia , nausea
• Weight gain (fluid retention)

Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialists no longer use it. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency, and ventricular failure.

Nursing Care Plans & Management

Nurses greatly influence the outcomes of patients with heart failure through education and monitoring despite high morbidity and mortality rates. Education empowers patients, improving adherence and preventing complications. Vigilant monitoring enables early intervention, reducing risks. Nurses play a crucial role in reducing HF morbidity and mortality.

The following are the nursing priorities for patients with congestive heart failure:

• Improve myocardial contractility and perfusion. Enhance heart’s pumping function to ensure adequate blood flow to organs through medications, monitoring vital signs, and optimizing fluid balance .
• Manage fluid volume. Monitor fluid balance, assess for signs of retention, administer diuretics , monitor weight, and promote adherence to a low- sodium diet.
• Prevent complications. Monitor for and manage complications such as pulmonary edema, arrhythmias, and thromboembolism through close monitoring, medication administration , and patient education.
• Promote activity tolerance . Encourage 30 minutes of daily physical activity (as tolerated), collaborate on a schedule, and prioritize activities.
• Reduce anxiety . Provide comfort , psychological support, and teach anxiety management techniques.
• Minimize powerlessness. Encourage patient expression of concerns and involve them in decision-making .
• Provide disease information and prevention education. Educate patients about heart failure, its impact, prognosis, lifestyle modifications, medication adherence, and seeking timely care to prevent worsening of symptoms.

Nursing assessment for patients with heart failure emphasizes evaluating the efficacy of treatment and the patient’s adherence to self-management strategies. Monitoring and reporting worsening signs and symptoms of heart failure are essential for adjusting therapy. Additionally, the nurse addresses the patient’s emotional well-being, as heart failure is a chronic condition linked to depression and psychosocial concerns

Health History

• Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue , and edema.
• Assess for sleep disturbances, especially sleep suddenly interrupted by shortness of breath.
• Explore the patient’s understanding of HF, self management strategies, and the ability and willingness to adhere to those strategies.

Physical Examination

• Auscultate the lungs for presence of crackles and wheezes.
• Auscultate the heart for the presence of an S3 heart sound.
• Assess JVD for presence of distention.
• Evaluate the sensorium and level of consciousness.
• Assess the dependent parts of the patient’s body for perfusion and edema.
• Assess the liver for hepatojugular reflux.
• Measure the urinary output carefully to establish a baseline against which to assess the effectiveness of diuretic therapy.
• Weigh the patient daily in the hospital or at home.

Assess for the following subjective and objective data:

• Increased heart rate (tachycardia)
• ECG changes
• Changes in BP (hypotension/ hypertension )
• Extra heart sounds (S3, S4)
• Decreased urine output (oliguria)
• Diminished peripheral pulses
• Jugular vein distention
• Changes in vital signs
• Presence of dysrhythmias
• Diaphoresis
• Weight gain
• Respiratory distress
• Abnormal breath sounds

Assess for factors related to the cause of congestive heart failure:

• Altered circulation
• Altered myocardial contractility/inotropic changes
• Alterations in rate, rhythm, electrical conduction
• Decreased cardiac output
• Structural changes (e.g., valvular defects, ventricular aneurysm)
• Poor cardiac reserve
• Side effects of medication
• Imbalance between oxygen supply/demand
• Prolonged bed rest
• Reduced glomerular filtration rate (decreased cardiac output)/increased antidiuretic hormone (ADH) production, and sodium/water retention.
• Changes in glomerular filtration rate
• Use of diuretics
• Lack of understanding
• Misconceptions about interrelatedness of cardiac function/disease/failure
• Invasive procedures
• Prolonged hospitalization
• Alveolar edema secondary to increased ventricular pressure
• Retained secretions
• Increased metabolic rate secondary to pneumonia

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with heart failure based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities. However, if you still find value in utilizing nursing diagnosis labels, here are some examples to consider:

• Decreased Cardiac Output related to impaired myocardial function as evidenced by signs of fatigue , dyspnea, and abnormal heart rate or blood pressure .
• Risk for Ineffective Health Maintenance related to lack of knowledge regarding diagnostic and laboratory procedures necessary for monitoring heart failure status.
• Impaired Gas Exchange related to fluid overload and pulmonary congestion as evidenced by [e.g., orthopnea, paroxysmal nocturnal dyspnea, and hypoxemia ].
• Excess Fluid Volume related to compromised heart function and renal perfusion as evidenced by [e.g., peripheral edema, ascites, and weight gain].
• Acute Pain related to decreased myocardial oxygenation as evidenced by [e.g., reports of chest pain or discomfort exacerbated by physical exertion or stress].
• Ineffective Tissue Perfusion (cardiopulmonary) related to decreased cardiac output as evidenced by [e.g., altered mental status, cool and clammy skin, and decreased urine output].
• Imbalanced Nutrition : Less Than Body Requirements related to dietary restrictions and fluid management in heart failure as evidenced by [e.g., confusion about low-sodium diet recommendations and fluid intake limits].
• Activity Intolerance related to imbalance between oxygen supply and demand as evidenced by [e.g., repotrs of fatigue , dyspnea on exertion, and decreased endurance].
• Anxiety related to changes in health status and uncertainty about the future due to heart failure diagnosis as evidenced by [e.g., patient’s verbalization of worries about their condition, noticeable restlessness, frequent questions about their prognosis, and expressed concerns regarding the effects of their illness on family roles and responsibilities].

Major goals for patients with heart failure include promoting physical activity, reducing fatigue, alleviating symptoms of fluid overload , managing anxiety, fostering patient empowerment in decision-making, and providing comprehensive health education to the patient and their family. Goals and expected outcomes may also include:

• The patient will exhibit optimal cardiac output, indicated by vital signs within acceptable ranges, absence/control of dysrhythmias, and absence of heart failure symptoms.
• The patient will engage in activities that reduce cardiac workload.
• The patient will actively participate in desired activities and meet their own self-care needs.
• The patient will maintain stable fluid volume, with balanced intake and output, clear/clearing breath sounds, vital signs within acceptable range, stable weight, and absence of edema.
• The patient will verbalize understanding of individual dietary and fluid restrictions.
• The patient will prioritize maintaining skin integrity .
• The patient will effectively manage pain.
• The patient will identify strategies to reduce anxiety.
• The patient will exhibit improved concentration.
• The patient will actively participate in their treatment regimen based on their abilities and situation.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with congestive heart failure may include:

A decrease in cardiac output in heart failure occurs because the heart muscle weakens or becomes stiff, impairing its ability to contract and relax properly. Initiating nursing interventions for a decrease in cardiac output in patients with congestive heart failure is important because it can help prevent the progression of the disease and decrease the risk of complications. Early recognition and management of decreased cardiac output can improve patient outcomes and quality of life.

1. Auscultate apical pulse, assess heart rate. Tachycardia is an early sign of heart failure. An increase in heart rate is the body’s first response to compensate for reduced cardiac output (CO). Initially, this compensatory response has a favorable effect on cardiac output, but over time, persistent tachycardia is harmful and may worsen heart failure. Appropriate heart rate control has been associated with better clinical outcomes, including decreased hospitalizations and mortality (Yancy et al., 2017).

2. Obtain a comprehensive health history focusing on HF symptoms and self-management strategies. Understanding the patient’s health history helps identify signs and symptoms of worsening HF and assess the patient’s understanding and adherence to self-management strategies.

3. Note heart sounds. An extra heart sound S 3 or ventricular gallop may be heard during auscultation ( S 3 mixtape here ). This is caused by a large volume of fluid entering the ventricle at the beginning of diastole (Drazner et al., 2003). S 1 and S 2 may be weak because of decreased pumping action. Murmurs may reflect valvular incompetence. Auscultate the heart for S3 heart sound and assess heart rate and rhythm. S3 heart sound is an early sign of increased blood volume in the ventricle, indicating worsening HF. Monitoring heart rate and rhythm helps identify abnormalities that may contribute to decreased cardiac output and guides treatment decisions.

4. Assess rhythm and document dysrhythmias if telemetry is available. Both atrial and ventricular dysrhythmias are common. Myocardial stretch, fibrosis, and chamber dilation all alter the electrical paths of the heart. Atrial fibrillation (AF) is common in patients with HF, and occurrence increases with HF severity (Maisel et al., 2003; Yancy et al., 2007). Atrial fibrillation promotes thrombus formation within the atria. Other common dysrhythmias associated with HF include premature atrial contractions, paroxysmal atrial tachycardia, PVCs, multifocal atrial tachycardia, ventricular tachycardia, and ventricular fibrillation.

5. Assess for palpitations or irregular heartbeat. Palpitations can occur due to dysrhythmias secondary to chronic heart failure. Atrial fibrillation is the most common dysrhythmia in HF. It can also be a compensatory mechanism as the failing heart tries to accommodate for the lack of flow with a faster HR (Kemp et al., 2012). Patients may report fast or irregular heartbeat.

6. Palpate peripheral pulses. Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post-tibial pulses. Marked diminution or absence of peripheral pulses can indicate severely depressed stroked volume or the presence of severe occlusive vascular disease (Leier, 2007). Pulses may be fleeting or irregular to palpation , and pulsus alternans (a strong beat alternating with a weak beat) may be present. Evaluating peripheral pulses and skin perfusion helps determine the adequacy of peripheral perfusion. Decreased pulse volume and cool, pale, or cyanotic skin may indicate decreased cardiac output and guide interventions.

7. Monitor blood pressure ( BP ). In acute heart failure, BP may be elevated because of increased systemic vascular resistance (SVR). BP is often used to determine interventions (e.g., vasodilators , vasopressors, etc.). In chronic heart failure, BP is used as a parameter to determine the adequacy or excess dosage of pharmacological therapy (e.g., administration of ACE inhibitors).

8. Inspect the skin for mottling. Low cardiac output can result in decreased perfusion to the skin of the extremities and may result in mottling – a blue or gray coloring of the skin (Albert et al., 2010). Because of increased tissue capillary oxygen extraction in chronic HF, the skin may appear dusky.

9. Inspects the skin for pallor or cyanosis. Cool or clammy feeling to touch can occur with diminished perfusion; hypoperfusion in the limb will render pallor (Leier, 2007; Bolger, 2003). This finding, along with other signs of systemic hypoperfusion, will assist the primary care provider to choose proper pharmacotherapy and interventions needed to manage the patient’s condition.

10. Monitor urine output, noting decreasing output and concentrated urine . Urine output may be decreased due to decreased renal perfusion – kidneys react to reduced cardiac output by retaining water and sodium. The patient may also develop resistance to diuretics, resulting in decreased urinary output (De Bruyne et al., 2003). Urine output is usually low during the day because fluid shifts into tissues and increases at night (nocturia) due to increased renal perfusion during supine position (Redeker et al., 2012).

11. Note changes in sensorium: lethargy , confusion , disorientation, anxiety, and depression. Cerebral hypoperfusion occurs because of hypoxia to the brain from the decreased cardiac output. The patient may report this as confusion , forgetfulness, or restlessness. Through assessment is necessary to evaluate for possible related conditions, including psychological disorders. Depression is common among patients with heart failure and can lead to poor adherence to treatment plans. Studies have shown depression is 4 to 5 times more common in patients with heart failure and confers a twofold risk of mortality and higher readmission rates (Joynt et al., 2004; Rutledge et al., 2006).

12. Evaluate the patient’s level of consciousness for changes that may indicate decreased cerebral perfusion. Low cardiac output in HF can result in decreased oxygen delivery to the brain, potentially causing alterations in consciousness. Assessing the patient’s level of consciousness helps detect any changes and guides appropriate interventions.

13. Examine lower extremities for edema and rate its severity. Edema is a common manifestation of HF. Assessing its presence and severity helps evaluate fluid status and guide diuretic therapy and fluid management.

14. Assess the abdomen for tenderness, hepatomegaly, and signs of ascites. Abdominal assessment provides information on potential complications of HF, such as hepatic congestion and ascites. Identifying these findings guides interventions and treatment decisions.

15. Assess jugular vein distention (JVD). JVD is assessed to estimate central venous pressure and identify right ventricular failure. Abnormal JVD, defined as distention greater than 4 cm above the sternal angle, suggests increased venous pressure and guides treatment decisions.

16. Monitor results of laboratory and diagnostic tests. Signs and symptoms of heart failure are not highly specific and may mimic many other medical conditions (Yancy et al., 2017). The goal in diagnosis is to find the underlying cause of HF and the patient’s response to treatment.

17. Monitor oxygen saturation and ABGs. Baseline oxygen saturation is useful in establishing the diagnosis and severity of heart failure in acute settings (Masip et al., 2012; Milo-Cotter et al., 2009). Additionally, this provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood.

18. Give oxygen as indicated by the patient’s symptoms, oxygen saturation , and ABGs. Supplemental oxygen increases oxygen availability to the myocardium and can help relieve symptoms of hypoxemia, ischemia, and subsequent activity intolerance (Giordano, 2005; Haque et al., 1996). The need is based on the degree of pulmonary congestion and resulting hypoxia. Ongoing pulse oximetry monitors the need for and effectiveness of oxygen supplementation.

19. Provide a restful environment and encourage periods of rest and sleep; assist with activities. Minimizing controllable stressors and unnecessary disturbances reduces cardiac workload and oxygen demand (Rogers et al., 2015). Physical and emotional rest allows the patient to conserve energy. The degree of rest depends on the severity of HF. Patients with severe HF may need to rest in bed, while those with mild to moderate HF can be ambulatory with limited activity.

20. Encourage rest, semirecumbent in bed or chair. Assist with physical care as indicated. During acute or refractory HF, physical rest should be maintained to improve cardiac contraction efficiency and decrease myocardial oxygen demand/ consumption and workload. Enforce complete bed rest when necessary to decrease the cardiac workload on acute symptomatic attacks of HF.

21. Provide a quiet environment: explain therapeutic management, help the patient avoid stressful situations, listen, and respond to expressions of feelings. Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate.

22. Assist the patient in assuming a high Fowler’s position . Allows for better chest expansion, thereby improving pulmonary capacity. In this position, the venous return to the heart is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. Additionally, heart failure with pulmonary congestion can cause a chronic nonproductive cough worsening in the recumbent position (Platz et al., 2017; Picano et al., 2010).

23. Check for calf tenderness, diminished pedal pulses, swelling, local redness, or pallor of extremity. The risk for thrombophlebitis increases with enforced bed rest, reduced cardiac output, and venous pooling.

24. Elevate legs, avoiding pressure under the knee or in a position comfortable to the patient. Decreases venous return and preload and may reduce the incidence of thrombus or embolus formation.

25. Reposition patient every two (2) hours . For patients under bed rest, prolonged immobility should be avoided because of its deconditioning effects and risk, such as pressure ulcers, especially in patients with edema. Decreased circulation in edematous areas also increases the risk of pressure ulcers.

26. Provide bedside commode, provide stool softeners as ordered. Have patient avoid activities eliciting a vasovagal response (straining during defecation, holding breath during position changes). Using a bedside commode decreases work of getting to the bathroom or struggling to use a bedpan. Patients with HF have autonomic dysfunction. Valsalva maneuver or similar behaviors reduces mean arterial blood pressure and cerebral blood flow, leaving patients vulnerable to hypoperfusion, ischemia, and stroke (Serber et al., 2014).

27. Encourage active and passive exercises. Increase activity as tolerated. For acute HF, bed rest may be temporarily indicated. Otherwise, a total of 30 minutes of physical activity every day should be encouraged (Yancy et al., 2017).

28. Administer medications as indicated. See Pharmacologic Management

29. Withhold digitalis preparation as indicated, and notify the physician if marked changes occur in cardiac rate or rhythm or signs of digitalis toxicity occur. The incidence of toxicity is high (20%) because of the narrow margin between therapeutic and toxic ranges. Digoxin may have to be discontinued in the presence of toxic drug levels, a slow heart rate, or low potassium level.

30. Administer IV solutions , restricting total amount as indicated. Avoid saline solutions. Because of existing elevated left ventricular pressure, the patient may not tolerate increased fluid volume ( preload ). The amount of fluid administered should be monitored closely (Bikdeli et al., 2015; Albert, 2012). Patients with HF also excrete less sodium, which causes fluid retention and increases cardiac workload.

31. Monitor for signs and symptoms of fluid and electrolyte imbalances . Fluid shifts and the use of diuretics can lead to excessive diuresis and may lead to electrolyte imbalances, such as hypokalemia (Oh et al., 2015). Signs of hypokalemia include ventricular dysrhythmias, hypotension, and generalized weakness . Hyperkalemia can occur with the use of ACE inhibitors, ARBs, or spironolactone .

32. Monitor serial electrocardiogram (ECG) and chest x-ray changes. Can indicate the underlying cause of HF. ST-segment depression and T-wave flattening can develop because of increased myocardial oxygen demand, even if no coronary artery disease is present. A chest X-ray may show an enlarged heart and pulmonary congestion.

33. Measure cardiac output and other functional parameters as indicated. Cardiac index, preload , afterload, contractility, and cardiac work can be measured noninvasively using the thoracic electrical bioimpedance (TEB) technique. Useful in determining the effectiveness of therapeutic interventions and response to activity.

34. Prepare for insertion and maintenance of pacemaker, if indicated. It may be necessary to correct bradydysrhythmias unresponsive to drug intervention. This can aggravate congestive failure and/or produce pulmonary edema.

35. Assist with mechanical circulatory support systems, such as the placement of a ventricular assist device (VAD). A battery-powered ventricular assist device (VAD) is positioned between the cardiac apex and the descending thoracic or abdominal aorta. This device receives blood from the left ventricle (LV) and ejects it into the systemic circulation, often allowing the patient to resume a nearly normal lifestyle while awaiting recovery, transplantation, or waiting for a decision (Yancy et al., 2017).

36. Recognize that some patients may need an intra-aortic balloon pump (IABP), and provide assistance. An intra-aortic balloon pump (IABP) may be inserted as temporary support to the failing heart in a critically ill patient with potentially reversible HF (Reid et al., 2005). When caring for a patient managed with IABP, the nurse must continually assess and measure the often subtle changes in patient’s condition. This requires expert knowledge of the cardiovascular system , therapeutic effects of IABP, and potential adverse events (Lewis et al., 2009). With end-stage HF, cardiac transplantation may be indicated.

37. Withhold digitalis preparation as indicated, and notify the physician if marked changes occur in cardiac rate or rhythm or signs of digitalis toxicity occur. The incidence of toxicity is high (20%) because of the narrow margin between therapeutic and toxic ranges. Digoxin may have to be discontinued in the presence of toxic drug levels, a slow heart rate, or low potassium level.

38. Administer IV solutions , restricting total amount as indicated. Avoid saline solutions. Because of existing elevated left ventricular pressure, the patient may not tolerate increased fluid volume (preload). The amount of fluid administered should be monitored closely (Bikdeli et al., 2015; Albert, 2012). Patients with HF also excrete less sodium, which causes fluid retention and increases cardiac workload.

39. Monitor for signs and symptoms of fluid and electrolyte imbalances . Fluid shifts and the use of diuretics can lead to excessive diuresis and may lead to electrolyte imbalances, such as hypokalemia (Oh et al., 2015). Signs of hypokalemia include ventricular dysrhythmias, hypotension, and generalized weakness. Hyperkalemia can occur with the use of ACE inhibitors, ARBs, or spironolactone.

40. Measure cardiac output and other functional parameters as indicated. Cardiac index, preload, afterload, contractility, and cardiac work can be measured noninvasively using the thoracic electrical bioimpedance (TEB) technique. Useful in determining the effectiveness of therapeutic interventions and response to activity.

Monitoring diagnostic procedures and laboratory studies is an essential aspect of caring for patients with heart failure. These assessments help healthcare professionals evaluate the severity of the condition, track progress, and guide treatment decisions. This helps healthcare providers make informed decisions about the patient’s care and adjust treatment plans as necessary.

1. Blood urea nitrogen (BUN) and creatinine. Elevation of BUN or creatinine reflects decreased renal perfusion, which may be caused by HF or medications (e.g., diuretics, ACE inhibitors).

2. Liver function studies (AST, LDH). May detect alterations in liver function which can demonstrate possible cause or effect. May also be elevated because of liver congestion and indicate a need for smaller dosages of medications.

3. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) coagulation studies. Helps in identifying patients at risk for excessive clot formation and measures changes in coagulation processes or the effectiveness of anticoagulant therapy.

4. Atrial natriuretic peptide (ANP). ANP is a hormone secreted from the right atrial cells when pressure increases. It is increased in congestive HF.

5. Beta-type natriuretic peptide (BNP). BNP is secreted from the cardiac ventricles as a response to ventricular volume and fluid overload (Cowie & Mendez, 2002). BNP levels in the blood increases when symptoms of HF worsen.

6. Electrocardiogram (ECG). Can indicate the underlying cause of HF. ST-segment depression and T-wave flattening can develop because of increased myocardial oxygen demand, even if no coronary artery disease is present.

7. Echocardiogram . This ultrasound test provides detailed images of the heart’s structure and function, including the size and thickness of the heart chambers, the strength of the heart’s contractions, and the ejection fraction (the percentage of blood pumped out with each heartbeat). Echocardiograms are regularly performed to assess cardiac function and monitor changes over time.

8. Cardiac stress test. This test evaluates the heart’s response to physical exertion or pharmacological stress. It is used to assess exercise capacity, identify exercise-induced arrhythmias, and determine if there are any underlying coronary artery blockages contributing to heart failure symptoms.

9. Complete blood count (CBC). A CBC measures various components of the blood, including red and white blood cells and platelets. It helps identify anemia , infection , or other abnormalities that may impact heart failure management.

10. Kidney function tests. Blood tests such as serum creatinine and blood urea nitrogen (BUN) are used to assess kidney function. Impaired kidney function is common in heart failure and may affect treatment options and medication dosages.

11. Electrolyte levels. Blood tests measure electrolyte levels, such as sodium, potassium, and magnesium . Imbalances in these electrolytes can affect heart rhythm and overall cardiac function.

12. Chest X-ray A chest X-ray may show an enlarged heart and pulmonary congestion.

Administering medication and providing pharmacological interventions are critical components of caring for patients with heart failure. Medications are prescribed to manage symptoms, improve heart function, prevent complications, and enhance the patient’s quality of life. These interventions can also help slow the progression of the disease and improve overall outcomes for the patient.

1. Diuretics Diuretics are first-line drugs for all patients with signs of volume overload. Diuretics work by reducing blood volume, therefore, decreasing venous pressure, arterial pressure, pulmonary edema, peripheral edema, and cardiac dilation (Ellison et al., 2017; Brater, 2000). Diuretics are essential in managing fluid overload in patients with heart failure. Loop diuretics, thiazide diuretics, and aldosterone antagonists have different mechanisms of action in the kidney, promoting increased urine production and removal of excess extracellular fluid . Administering the prescribed diuretic helps alleviate symptoms of fluid overload and improve the patient’s overall condition. Data from several small controlled trials show that conventional diuretics appear to reduce the risk of death and worsening heart failure compared to a placebo in patients with CHF. About 80 deaths may be avoided for every 1000 people treated. Diuretics also increase the ability to exercise by about 28% to 33% more than other active drugs (Faris et al., 2012).

Commonly used diuretics for patients with heart failure include:

• Thiazide diuretics [hydrochlorothiazide (Microside)] are oral agents that produce moderate diuresis and are used for long-term therapy of heart failure when edema is moderate (Sica et al, 2011; De Bruyne et al, 2003). Thiazides are ineffective when the GFR is low and if the cardiac output is severely reduced. Adverse effects of thiazides include hypokalemia (thereby increasing risk of digoxin-induced dysrhythmias).
• Loop diuretics [ furosemide (Lasix), ethacrynic acid (Edecrin)] promote fluid loss even when GFR is low, in contrast with thiazides. Loop diuretics are the drug of choice for patients with severe heart failure (Felker, 2012). Other than hypokalemia, loop diuretics can also cause severe hypotension due to excessive fluid volume loss. Furosemide also reduces alveolar congestion, enhancing gas exchange .
• Potassium-sparing diuretics [spironolactone (Aldactone)] are used to counteract potassium loss caused by thiazide and loop diuretics, thereby reducing the risk of digoxin-induced dysrhythmias (Gao et al, 2007). Hyperkalemia is the principal adverse effect of these drugs (Brater, 2000).

Nursing interventions and actions for patients taking diuretics may include:

• Monitor and document the patient’s fluid intake and output, including daily weight measurements. Monitoring and documenting fluid intake and output, along with daily weight measurements, are crucial in evaluating the effectiveness of diuretic therapy. These parameters help assess the response to diuretics, determine the need for dosage adjustments, and identify any excessive fluid retention or depletion. Changes in weight can be an early indicator of fluid shifts. Tracking fluid intake and output provides valuable information on fluid balance. Comparing intake and output with weight changes helps evaluate the effectiveness of diuretic therapy and guides fluid management decisions.
• Monitor serum potassium levels regularly and report any abnormalities. Certain diuretics, such as loop diuretics and thiazide diuretics, increase potassium excretion, potentially leading to hypokalemia. Regular monitoring of serum potassium levels allows for early detection of imbalances and enables prompt intervention, such as adjusting the diuretic dosage or prescribing potassium supplements, to maintain optimal electrolyte balance.
• Educate the patient about the importance of adhering to a low-sodium diet and restricting fluid intake. A low-sodium diet, along with fluid restriction, helps reduce fluid overload and decrease the reliance on diuretics. Educating the patient about dietary modifications and fluid management strategies promotes self-care and empowers the patient to actively participate in their treatment plan, ultimately improving outcomes and reducing the burden of heart failure symptoms.
• Assess for signs and symptoms of orthostatic hypotension and kidney injury . Diuretic therapy can lead to orthostatic hypotension, especially in patients prone to volume depletion. Regular assessment for symptoms such as dizziness, lightheadedness, or syncope when changing positions helps identify orthostatic hypotension and guide appropriate interventions. Additionally, close monitoring for kidney injury, indicated by changes in urine output or renal function, is important to ensure early detection and management.
• Monitor serum creatinine and potassium levels frequently, especially during the initiation of aldosterone antagonists (e.g., spironolactone). Aldosterone antagonists, such as spironolactone, are potassium-sparing diuretics that require careful monitoring of serum creatinine and potassium levels. Close monitoring, particularly during the initial phase of treatment, helps detect any changes or abnormalities that may indicate renal impairment or potassium imbalance. Prompt intervention or dosage adjustments can then be made to ensure patient safety .
• Evaluate the patient’s response to diuretic therapy and assess for the development or worsening of cardiorenal syndrome. Monitoring the patient’s response to diuretic therapy is essential to evaluate its effectiveness in relieving

2. Vasodilators, arterial dilators, and combination drugs. Vasodilators treat heart failure by increasing cardiac output, reducing circulating volume, and decreasing systemic vascular resistance – ultimately reducing ventricular workload. Commonly used vasodilators include:

• Isosorbide dinitrate (ISDN) [Nitro Dur, Isordil] causes selective dilation of veins. For patients with severe refractory HF, ISDN can reduce congestive symptoms and improve exercise capacity (Ziaeian et al, 2017; Nyolczas et al, 2017; Cohn et al, 1991). Watch out for adverse effects such as orthostatic hypotension and reflex tachycardia.
• Hydralazine [Apresoline] causes selective dilation of arterioles, therefore, can help improve cardiac output and renal blood flow (Herman, 2017; Jacobs, 1984). Hydralazine is always used in combination with ISDN (e.g., BiDil – a fixed-dose combination of hydralazine and ISDN).
• Nitroglycerin when given intravenously, is a powerful vasodilator that produces a dramatic reduction in venous pressure. It is also used to relieve acute severe pulmonary edema (Levy et al, 2007). Hypotension and reflex tachycardia are its main adverse effects.
• Sodium nitroprusside [Nitropress] rapidly dilates arterioles and veins. Arteriolar dilation reduces afterload and thereby increasing cardiac output. Venodilation reduces venous pressure, thereby reducing pulmonary and peripheral congestion. Note: Blood pressure must be monitored continuously when taking this drug.
• Nesiritide administration leads to a rapid and balanced vasodilatory effect, which results in a significant decrease in right and left ventricular filling pressures and systemic vascular resistance and at the same time in an increase in stroke volume and cardiac output without a change in heart rate. (Elkayam et al, 2002). Nesiritide treatment significantly increased left ventricular ejection fraction, cardiac index, and 24- and 72-hour urine volumes. The drug safely improves global cardiac and systemic function for patients with heart failure (Zhao et al, 2020).

3. Angiotensin-converting Enzyme Inhibitors (ACE Inhibitors) [benazepril (Lotensin), captopril (Capoten), lisinopril (Prinivil), enalapril (Vasotec), quinapril (Accupril), ramipril (Altace), moexipril (Univasc)] blocks the renin-angiotensin-aldosterone-system (RAAS) by inhibiting the conversion of angiotensin I to angiotensin II. They decrease mortality, morbidity, hospitalizations, and symptoms in patients with heart failure (Yancy et al., 2017). These drugs also decrease the release of aldosterone and suppress the degradation of kinins. As a result, they improve hemodynamics and favorably alter cardiac remodeling. Additionally, observe for symptomatic hypotension, hyperkalemia, cough, and worsening renal function. Additional nursing interventions for patients taking ACE inhibitors may include:

• Monitor vital signs, including blood pressure , before and after administering ACE inhibitors. Monitoring vital signs, especially blood pressure , is essential when initiating ACE inhibitor therapy. These medications promote vasodilation, which can potentially cause hypotension. Regular monitoring allows for early detection and intervention in case of significant changes in blood pressure.
• Monitor serum potassium levels regularly. ACE inhibitors can cause hyperkalemia (increased potassium levels) due to their effect on inhibiting aldosterone secretion. Monitoring serum potassium levels allows for early detection of hyperkalemia, especially in patients concurrently receiving diuretics that may also affect potassium balance. Appropriate interventions can then be implemented to prevent complications.
• Educate the patient about the importance of compliance with medication regimen and regular follow-up appointments. Ensuring patient understanding and adherence to the prescribed ACE inhibitor regimen is crucial for optimal treatment outcomes. Education should include information about the benefits of ACE inhibitors, potential side effects, and the importance of attending regular follow-up appointments to monitor medication effectiveness, adjust dosages, and address any concerns or adverse reactions.
• Assess for the presence of a dry, persistent cough and report it to the primary care provider. A dry, persistent cough is a common side effect of ACE inhibitors. It is important to assess and monitor the patient for this adverse effect, as it may persist and affect the patient’s quality of life. Additionally, a persistent cough may also indicate a worsening of ventricular function and heart failure, necessitating further evaluation and intervention.
• Monitor for signs and symptoms of angioedema, such as swelling of the face, lips, or throat, and report immediately. Although rare, angioedema can occur as an allergic reaction to ACE inhibitors. It is a potentially life-threatening condition, particularly if it affects the oropharyngeal area and impairs breathing. Immediate discontinuation of the ACE inhibitor and provision of emergency care are essential to ensure patient safety and prevent further complications.
• Collaborate with the healthcare provider to adjust ACE inhibitor dosage based on the patient’s blood pressure, fluid status, renal function, and severity of heart failure. The optimal dosage of ACE inhibitors depends on various factors, including the patient’s blood pressure, fluid status, renal function, and severity of heart failure. Collaborating with the healthcare provider helps determine the appropriate dosage for each patient, ensuring that the medication is effective while minimizing the risk of adverse effects.

4. Angiotensin II receptor blockers (ARBs) [eprosartan (Teveten), irbesartan (Avapro), valsartan (Diovan)] are for patients who are unable to tolerate ACE inhibitors (usually owing to intractable cough). They prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites. ARBs promote afterload reduction and vasodilation, improve LV ejection fraction, reduce heart failure symptoms, increase exercise tolerance, decrease hospitalization, enhance the quality of life, and reduce mortality (Yancy et al., 2017). Monitoring is the same as ACE inhibitors.

5. Cardiac glycosides [Digitalis (Lanoxin)] Digoxin is a cardiac glycoside that increases the myocardial contractile force (positive inotropic action). By increasing contractile force, digoxin can increase cardiac output. It also slows the conduction of the heart through the AV node. Unfortunately, digitalis does not result in decreased mortality rates in patients with HF though effective in preventing hospital readmission and decreasing symptoms of systolic HF (Alkhawam et al., 2019; Qamer et al., 2019). Digitalis is considered a second-line agent for heart failure and was widely used in the past. Monitor the renal function and serum potassium levels of patients taking digitalis. Regular monitoring of renal function and serum potassium levels is essential to adjust digoxin dosage and prevent toxicity. Clinical manifestations of digoxin toxicity, such as anorexia, nausea, visual disturbances, confusion , and bradycardia, should be assessed and documented. Serum digoxin levels are obtained if renal function changes or toxicity symptoms occur. Patient education about digoxin toxicity signs, adherence to medication and monitoring, and prompt reporting of concerning symptoms is crucial.

6. Inotropic agents [amrinone (Inocor), milrinone (Primacor), vesnarinone (Arkin-Z), dobutamine [Dobutrex]] . These medications are useful for short-term or acute treatment of HF unresponsive to cardiac glycosides, vasodilators, and diuretics to increase myocardial contractility and produce vasodilation. They are given intravenously. Positive inotropic properties have reduced mortality rates by 50% and improved quality of life.

Additional nursing interventions for patients taking inotropic agents:

• Administer IV inotropes, such as milrinone (Primacor) or dobutamine (Dobutrex), to hospitalized patients with acute decompensated heart failure (HF) who do not respond to routine pharmacologic therapy. IV inotropes are used in patients with severe ventricular dysfunction and acute decompensated HF who do not respond to standard pharmacologic treatments. Milrinone and dobutamine increase myocardial contractility and can be effective in improving cardiac function. Administering these medications helps support cardiac output and perfusion in critically ill patients.
• Monitor blood pressure closely before and during the administration of milrinone, as it can cause hypotension. Milrinone promotes vasodilation, leading to decreased preload and afterload. Monitoring blood pressure before and during administration is crucial, especially in hypovolemic patients, as rapid drops in blood pressure can occur. Close monitoring allows for timely intervention and adjustment of medication dosage to maintain hemodynamic stability.
• Monitor blood pressure, ECG, and cardiac rhythm closely during and following infusions of milrinone. Close monitoring of blood pressure, electrocardiogram (ECG), and cardiac rhythm during and after milrinone infusions is necessary. Hypotension and increased ventricular dysrhythmias are major side effects of milrinone. Regular assessment of these parameters allows for early detection of adverse reactions and prompt interventions, ensuring patient safety.
• Administer dobutamine to patients with significant left ventricular dysfunction and hypoperfusion. Dobutamine is an IV medication used in patients with significant left ventricular dysfunction and inadequate tissue perfusion . It stimulates beta-1 adrenergic receptors, increasing cardiac contractility and renal perfusion, which enhances urine output. Administering dobutamine improves cardiac function and promotes adequate organ perfusion in critically ill patients.
• Monitor heart rate and rhythm closely during dobutamine administration, as it can increase heart rate and precipitate ectopic beats and tachydysrhythmias. Dobutamine action in stimulating beta-1 adrenergic receptors increases heart rate and can lead to the development of ectopic beats and tachydysrhythmias. Regular monitoring of heart rate and rhythm allows for early detection of any abnormalities or adverse effects. Prompt intervention can be implemented to manage dysrhythmias and ensure patient stability.
• Monitor and document hemodynamic data, including cardiac function and volume status, when utilizing IV inotropes, vasodilators, and diuretics. Monitoring and documenting hemodynamic data, including cardiac function and volume status, is crucial in managing patients receiving IV inotropes, vasodilators, and diuretics. Hemodynamic data provide valuable information about cardiac performance, fluid status, and response to therapy. These parameters guide treatment decisions, dose adjustments, and overall patient management in the intensive care unit (ICU) setting.
• Assess the patient’s need for continuous IV inotropic therapy at home if they cannot be weaned from IV inotropes and have end-stage heart failure. In some cases, patients with end-stage heart failure may require continuous IV inotropic therapy at home if they cannot be weaned off IV inotropes. Assessing the patient’s response to treatment, stability, and overall prognosis helps determine the need for home-based therapy. Continuous therapy requires careful monitoring and coordination with healthcare providers to ensure safety and optimal management of heart failure.

7. Beta-Blockers: Beta-adrenergic receptor antagonists [carvedilol (Coreg), bisoprolol (Zebeta), metoprolol (Lopressor)]. Beta-blockers are considered first-line therapy in the management of heart failure. They block the adverse effects of the sympathetic nervous system , leading to vasodilation, reduced blood pressure, decreased afterload, and decreased cardiac workload. Administering beta-blockers helps improve functional status, reduce mortality and morbidity, and prevent the onset of heart failure symptoms in patients with asymptomatic systolic dysfunction. Careful control of the dosage of beta-blockers can improve patient status by improving LV ejection fraction, increasing exercise tolerance, slowing HF progression, reducing the need for hospitalization, and prolong survival (Butler et al., 2006; Barrese et al., 2013). Side effects to look out for include worsening HF symptoms, hypotension, fatigue, and bradycardia. Additional nursing interventions for patients with heart failure taking beta blockers may include:

• Monitor vital signs, including blood pressure and heart rate, before and after administering beta-blockers. Monitoring vital signs, especially blood pressure and heart rate, is essential when initiating beta-blocker therapy. These medications lower blood pressure and can cause bradycardia. Regular monitoring allows for early detection and intervention in case of significant changes in blood pressure or heart rate.
• Educate the patient about the gradual titration of beta-blocker dosage and the expected delay in therapeutic effects. Beta-blockers are started at a low dose and gradually titrated up over several weeks to minimize potential side effects. It is important to educate the patient about this dosing regimen and explain that therapeutic effects may not be seen immediately. Providing this information helps manage patient expectations and promotes adherence to the treatment plan.
• Assess and document the patient’s response to beta-blocker therapy, including the presence of side effects. Monitoring the patient’s response to beta-blocker therapy is crucial to ensure effectiveness and detect any adverse effects. Close assessment and documentation of side effects, such as dizziness, hypotension, bradycardia, fatigue, and depression, are important to inform healthcare providers and guide appropriate interventions or dosage adjustments.
• Provide support and reassurance to patients experiencing side effects during the initial phase of beta-blocker treatment. Side effects of beta-blockers are most common in the early weeks of treatment. Patients may experience symptoms such as dizziness, hypotension, bradycardia, fatigue, and depression. Offering support, reassurance, and education about the temporary nature of these side effects can help alleviate patient concerns and enhance adherence to the treatment plan.
• Assess the patient’s respiratory status, especially in those with a history of bronchospastic diseases such as uncontrolled asthma . Beta-blockers can cause bronchoconstriction, which can be problematic for patients with a history of bronchospastic diseases like uncontrolled asthma. Regular assessment of respiratory status helps identify any worsening of symptoms or potential complications related to bronchoconstriction, allowing for prompt intervention and adjustment of the treatment plan if necessary.
• Document and report any significant changes or concerns related to the patient’s cardiovascular or respiratory status to the primary care provider. Timely documentation and reporting of significant changes or concerns related to the patient’s cardiovascular or respiratory status are crucial for ongoing monitoring and appropriate interventions. This information helps healthcare providers make informed decisions regarding dosage adjustments, additional therapies, or potential medication changes to optimize patient outcomes .

8. Morphine sulfate Decreases vascular resistance and venous return, reducing myocardial workload, especially when pulmonary congestion is present. The use of morphine should be reserved for patients with myocardial ischemia who are refractory to drugs that favorably alter myocardial oxygen supply and demand. Morphine should not be used in patients whose chest pain syndrome has not been treated with nitrates and beta-blockers (Conti, 2011). Additionally, morphine can help allay anxiety and break anxiety’s feedback cycle to catecholamine release to anxiety.

9. Antianxiety agents and sedatives. Promote rest, reducing oxygen demand and myocardial workload. Patients with HF are likely to be restless and anxious and may feel overwhelmed by breathlessness due to their difficulty maintaining adequate oxygenation (Hinkle et al., 2017). Emotional stress can stimulate the SNS, ultimately increasing cardiac workload. By decreasing anxiety, the patient’s cardiac workload also decreases (De Jong et al., 2011). Additionally, patients with HF have a high incidence of depression and is linked with increased morbidity and mortality (Joynt et al., 2014). (see: Anxiety nursing diagnosis)

10. Anticoagulants: low-dose heparin , warfarin ( Coumadin ). Prescribed to patients with a history of atrial fibrillation or thromboembolic event. Anticoagulants are used prophylactically to prevent thrombus and embolus formation in the presence of risk factors such as venous stasis, enforced bed rest, cardiac dysrhythmias, and history of previous thrombotic episodes (Kim et al., 2018; Amin et al., 2019). Regular monitoring of the patient’s INR and PT is essential to evaluate the effectiveness and safety of anticoagulant therapy. These laboratory values provide information about the patient’s coagulation status and the therapeutic range of the anticoagulant being administered. Monitoring allows for dosage adjustments and ensures that the patient is within the target therapeutic range, minimizing the risk of bleeding or clotting complications.

11. Bronchodilators: aminophylline Increases oxygen delivery by dilating small airways and exerts mild diuretic effect to aid in reducing pulmonary congestion.

Maintaining or improving respiratory function is necessary for the care of patients with heart failure. As heart failure progresses, it can lead to fluid accumulation in the lungs, causing respiratory symptoms and compromising breathing. Nurses play a vital role in maintaining and improving respiratory function in patients with heart failure. Their proactive monitoring, patient education, and collaboration with the healthcare team help optimize respiratory care, reduce respiratory symptoms, and enhance the overall well-being of individuals with heart failure.

1. Assess respiratory rate, use of accessory muscles, signs of air hunger, lung excursion, cyanosis, and significant changes in vital signs. Monitoring respiratory parameters provides information on the patient’s respiratory status, the severity of pulmonary congestion, and the effort required for breathing. It helps identify potential respiratory complications and guides appropriate interventions. These are warning signs of increasing respiratory distress that requires immediate attention.

2. Auscultate breath sounds, noting crackles and wheezes. Reveals presence of pulmonary congestion and collection of secretions, indicating the need for further intervention. Decreased breath sounds can be a sign of fluid overload or altered ventilation. Crackles indicate the sudden opening of edematous airways and alveoli, while wheezes may suggest bronchospasm associated with pulmonary congestion. Identifying abnormal lung sounds aids in the assessment of HF severity and guides treatment decisions.

3. Monitor oxygen saturation and ABG findings. A 92% or less pulse oximetry value, decreased PaO 2 , and increased PaCO 2 are signs of decreasing oxygenation .

4. Observe the color of skin, mucous membranes, and nail beds, noting the presence of peripheral cyanosis. Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever / chills.

5. Monitor potassium levels. A possibility of hypokalemia is evident in patients taking diuretics.

6. Instruct patient in effective coughing and deep breathing. Clears airways and facilitates oxygen delivery.

7. Encourage frequent position changes. Helps prevent atelectasis and pneumonia.

8. Position the patient in a High Fowler’s position with the head of the bed elevated up to 90°. Promote maximal inspiration and enhance expectoration of secretions to improve ventilation.

9. Suction secretions PRN To clear the airway when secretions are blocking the airway.

10. Graph graph serial ABGs, pulse oximetry. Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF. Note: Research suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7% in patients with abnormal cardiac index.

11 Administer supplemental oxygen as indicated. For patients with ADHF, high-flow oxygen is given via a non-rebreathing mask, positive airway pressure devices, or endotracheal intubation and mechanical intubation. If it improves, oxygen is titrated to maintain pulse oximetry readings greater than 92%.

12. Administer medications as indicated . See Pharmacologic Management

13. Assist patient to use relaxation techniques Reduces muscle tension , decreases work of breathing

The patient’s fluid status is closely monitored through methods like auscultating the lungs, tracking daily body weight, and supporting the patient in following a low-sodium diet. Severe heart failure patients may undergo IV diuretic therapy, while those with milder symptoms usually receive oral diuretics. It’s important to note that a single dose of a diuretic can lead to a significant volume of fluid being excreted shortly after administration. Nursing interventions focus on monitoring fluid balance, promoting fluid restriction, administering diuretic medications, and providing patient education to optimize fluid balance and alleviate symptoms.

1. Monitor urine output, noting amount and color, as well as the time of day when diuresis occurs. Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night and/or during bed rest. Monitoring urinary output helps evaluate renal function and the effectiveness of diuretic therapy. Oliguria or anuria may indicate renal dysfunction, requiring further assessment and intervention.

2. Monitor and calculate 24-hour intake and output (I&O) balance. In patients receiving IV fluids and medications, close monitoring of fluid intake is crucial. Consultation with the primary provider or pharmacist can help determine if it is possible to maximize medication dosage within the same volume of IV fluid, such as double concentrating to reduce fluid volume. It’s important to note that diuretic therapy may lead to a sudden loss of fluid, resulting in circulating hypovolemia , even if edema or ascites persists.

3. Maintain chair or bed rest in semi-Fowler’s position during an acute phase. Positioning plays a crucial role in facilitating breathing for patients with respiratory difficulties. This can be achieved by increasing the number of pillows, elevating the head of the bed, or having the patient sit in a recliner. These positions help reduce venous return to the heart, alleviate pulmonary congestion, and minimize pressure on the diaphragm. Supporting the lower arms with pillows can also relieve fatigue and strain on the shoulder muscles caused by the patient’s weight.

4. Establish a fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care. Ice chips can be part of the fluid allotment. Involving patients in the therapeutic regimen may enhance a sense of control and cooperation with restrictions.

5. Weigh daily. Frequently monitor blood urea nitrogen, creatinine, and serum potassium, sodium, chloride, and magnesium levels. Monitoring and documenting changes in edema is important to assess the effectiveness of therapy in managing fluid retention. In heart failure patients, a weight gain of 5 pounds is roughly equivalent to 2 liters of fluid accumulation. Conversely, the use of diuretics can lead to excessive fluid shifts and subsequent weight loss . By collaborating with the patient, the nurse can assist in developing a fluid intake plan that adheres to prescribed restrictions while accommodating the patient’s dietary preferences. This comprehensive approach promotes balanced fluid management and supports the patient in maintaining a healthy diet.

6. Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema (check for pitting); note the presence of generalized body edema (anasarca). Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet and ankles (or dependent areas) and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion (associated with RHF) eventually results in systemic tissue edema.

7. Auscultate breath sounds, noting decreased and/or adventitious sounds (crackles, wheezes). Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, persistent cough. Excess fluid volume can cause pulmonary congestion, leading to symptoms such as dyspnea, cough, and orthopnea. To effectively manage fluid levels, the patient’s fluid status is carefully monitored through lung auscultation, daily body weight measurements, and adherence to a low-sodium diet. It is important to note that symptoms of pulmonary edema associated with left-sided heart failure may have a more acute onset, while respiratory symptoms related to right-sided heart failure may develop more gradually and be harder to alleviate.

8. Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, a sensation of suffocation, feelings of panic, or impending doom. May indicate the development of complications (pulmonary edema and/or embolus) and differs from orthopnea paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention.

9. Administer oral diuretics in the morning. Oral diuretics are commonly prescribed for patients with heart failure with less severe symptoms. Administering them in the morning helps prevent interference with the patient’s nighttime rest and reduces the likelihood of nocturia, urinary urgency, or incontinence , especially in older patients.

10. Monitor fluid status closely. Regular monitoring of the patient’s fluid status is essential. Auscultating the lungs helps assess for signs of pulmonary congestion, while daily body weight measurements provide information on fluid retention. Weight gain in patients with heart failure typically indicates fluid accumulation.

11. Promote adherence to a low-sodium diet. Assist the patient in adhering to a low-sodium diet by educating them on reading food labels and avoiding high-sodium foods, such as canned, processed, and convenience foods. Sodium restriction helps prevent fluid retention and reduces the workload on the heart.

12. Plan fluid intake throughout the day. If the patient requires fluid restriction, collaborate with them to plan fluid intake throughout the day while considering their dietary preferences. This approach promotes adherence to the prescribed fluid restriction while maintaining hydration.

13. Monitor IV fluids and consult with the primary provider or pharmacist. If the patient receives IV fluids and medications, closely monitor the fluid volume and consult with the primary provider or pharmacist regarding the possibility of maximizing medication concentration in the same volume of IV fluid. This approach helps minimize the overall fluid intake while ensuring effective medication administration.

14. Position the patient for optimal breathing. Assist the patient in assuming positions that facilitate easier breathing, such as elevating the head of the bed, using extra pillows, or sitting in a recliner. These positions reduce venous return to the heart (preload), alleviate pulmonary congestion, and minimize pressure on the diaphragm, thus improving respiratory comfort .

15. Assess for and prevent pressure ulcers. Edematous areas are at an increased risk of pressure ulcers due to decreased circulation. Regularly assess the patient’s skin for signs of breakdown and implement preventive measures. Positioning techniques that relieve pressure and frequent changes in position help prevent pressure ulcers and maintain skin integrity .

16. Monitor BP and central venous pressure (CVP) Hypertension and elevated CVP suggest fluid volume excess and may reflect developing pulmonary congestion, heart failure.

17. Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distension, constipation . Visceral congestion (occurring in progressive heart failure) can alter intestinal function.

18. Obtain patient history to ascertain the probable cause of the fluid disturbance. May include increased fluids or sodium intake or compromised regulatory mechanisms.

19. Monitorfor distended neck veins and ascites Indicates fluid overload.

20. Evaluate urine output in response to diuretic therapy. In HF management, severe cases often require IV diuretic therapy, while less severe symptoms are treated with oral diuretics. Administering oral diuretics in the morning helps prevent disruption of the patient’s nighttime rest. It is important to consider timing of medication administration, particularly for older patients who may experience urinary urgency or incontinence . A single dose of diuretic can lead to significant fluid excretion shortly after taking the medication. The focus is on monitoring the response to the diuretics rather than the actual amount voided.

21. Assess the need for an indwelling urinary catheter. Treatment focuses on diuresis of excess fluid.

22. Auscultate breath sounds q 2hr and pm for the presence of crackles and monitors for frothy sputum production When increased pulmonary capillary hydrostatic pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is developing pulmonary edema.

23. Assess for the presence of peripheral edema. Do not elevate legs if the client is dyspneic. Decreased systemic blood pressure to stimulation of aldosterone, which causes increased renal tubular reabsorption of sodium Low-sodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess.

24. Measure abdominal girth, as indicated. In progressive right-sided heart failure, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites).

25. Palpate abdomen. Note reports of right upper quadrant pain and tenderness. Advancing HF leads to venous congestion, resulting in abdominal distension, liver engorgement (hepatomegaly), and pain. This can alter liver function and prolong drug metabolism.

26. Encourage verbalization of feelings regarding limitation s. Expression of feelings may decrease anxiety, which is an energy drain that can contribute to feelings of fatigue.

27. Weigh the patient daily and compare to the previous measurement. Bodyweight is a sensitive indicator of fluid balance, and an increase indicates fluid volume excess. Daily weight monitoring is essential for assessing fluid balance in patients with heart failure. Significant weight gain may indicate fluid retention, prompting adjustments in medication, such as diuretic dosing.

28. Follow a low-sodium diet and/or fluid restriction The client senses thirst because the body senses dehydration . Oral care can alleviate the sensation without an increase in fluid intake.

29. Encourage or provide oral care q2 Heart failure causes venous congestion, resulting in increased capillary pressure. When hydrostatic pressure exceeds interstitial pressure, fluids leak out of the capillaries and present as edema in the legs and sacrum. Elevation of legs increases venous return to the heart.

30. Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated. To prevent pressure ulcers, the nurse assesses the patient for skin breakdown and implements preventive measures, considering the increased risk in areas affected by edema. This includes proper positioning to alleviate pressure and regular repositioning. The nurse recognizes that edema, impaired circulation, inadequate nutrition, and prolonged immobility, such as bed rest, are factors that can collectively compromise skin integrity . Close monitoring and proactive interventions are essential in maintaining skin health.

31. Provide small, frequent, easily digestible meals. Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion/ prevent abdominal discomfort.

32. Institute/instruct patient regarding fluid restrictions as appropriate. This helps reduce extracellular volume.

33. Administer medications as indicated . See Pharmacologic Management

34. Maintain fluid and sodium restrictions as indicated. Reduces total body water and prevents fluid reaccumulation.

35. Consult with a dietitian. It may be necessary to provide a diet that meets caloric needs within sodium restriction to the patient.

36. Monitor chest x-ray. Reveals changes indicative of resolution of pulmonary congestion.

37. Assist with rotating tourniquets and/or phlebotomy, dialysis, or ultrafiltration as indicated. Although not frequently used, mechanical fluid removal rapidly reduces circulating volume, especially in pulmonary edema refractory to other therapies.

Providing perioperative nursing care for patients with heart failure requires special attention and consideration to ensure their safety and optimize outcomes. By implementing these perioperative nursing interventions, nurses contribute to the safe and effective management of patients with heart failure throughout the surgical journey. Their expertise, close monitoring, and collaborative approach help ensure patient safety, minimize complications and promote positive surgical outcomes.

There are several surgeries that may be performed for the treatment of heart failure, including:

1. Coronary artery bypass graft (CABG) surgery. Coronary artery bypass graft (CABG) surgery involves creating a new pathway for blood to flow to the heart by bypassing blocked or narrowed coronary arteries. Nursing interventions for CABG surgery may include:

• Monitor the patient’s vital signs, including blood pressure, heart rate, and oxygen saturation levels.
• Assess the patient’s pain and administer pain medication as needed.
• Monitor for signs of bleeding or infection.
• Assist the patient with deep breathing and coughing exercises to prevent respiratory complications.
• Provide patient education on wound care and activity restrictions postoperatively.

2. Heart valve replacement surgery. Heart valve replacement surgery involves replacing a damaged or diseased heart valve with a prosthetic valve. Nursing interventions for heart valve replacement surgery may include:

• Monitor the patient’s vital signs and cardiac function.
• Administer medications to manage pain, prevent infection, and prevent blood clots.
• Provide patient education on medications, activity restrictions, and follow-up care.

3. Angioplasty. Angioplasty is a minimally invasive procedure used to open blocked or narrowed blood vessels, typically arteries supplying the heart. During angioplasty, a thin tube with a balloon at the tip is inserted into the blocked vessel and inflated to widen the artery and improve blood flow. Nursing interventions for angioplasty include:

• Obtain informed consent from the patient.
• Prepare the patient physically and emotionally for the procedure, and address any concerns or questions.
• Assist the healthcare team in positioning the patient for the procedure.
• Monitor the patient’s vital signs, including blood pressure, heart rate, and oxygen saturation levels, throughout the procedure.
• Assist with documentation.
• Provide instructions to the patient on post-procedure care, including wound care , activity restrictions, and medications.

4. Cardiomyoplasty. Cardiomyoplasty is an experimental procedure in which the latissimus dorsi muscle is wrapped around the heart and electrically stimulated to contract with each heartbeat. It may be done to augment ventricular function while the patient is awaiting cardiac transplantation or when transplantation is not an option. The benefit of cardiomyoplasty in the treatment of HF remains unclear (Bocchi, 2001). The challenge for the clinical application of cardiomyoplasty is that it is a major surgical procedure, and the benefits obtained are limited. Cardiomyoplasty is usually not recommended due to unfavorable results.

5. Transmyocardial revascularization. Other new surgical techniques include transmyocardial revascularization (percutaneous [PTMR]) using CO2 laser technology, in which a laser is used to create multiple 1-mm diameter channels in viable but underperfused cardiac muscle.

6. Prepare for insertion and maintenance of pacemaker, if indicated. It may be necessary to correct bradydysrhythmias unresponsive to drug intervention. This can aggravate congestive failure and/or produce pulmonary edema.

7. Assist with mechanical circulatory support systems, such as the placement of a ventricular assist device (VAD). A battery-powered ventricular assist device (VAD) is positioned between the cardiac apex and the descending thoracic or abdominal aorta. This device receives blood from the left ventricle (LV) and ejects it into the systemic circulation, often allowing the patient to resume a nearly normal lifestyle while awaiting recovery, transplantation, or waiting for a decision (Yancy et al., 2017).

8. Recognize that some patients may need an intra-aortic balloon pump (IABP), provide assistance. An intra-aortic balloon pump (IABP) may be inserted as temporary support to the failing heart in a critically ill patient with potentially reversible HF (Reid et al., 2005). When caring for a patient managed with IABP, the nurse must continually assess and measure the often subtle changes in patient’s condition. This requires expert knowledge of the cardiovascular system, therapeutic effects of IABP, and potential adverse events (Lewis et al., 2009). With end-stage HF, cardiac transplantation may be indicated.

Heart failure can cause a variety of symptoms that can lead to distress and discomfort for patients. Acute pain may arise from factors such as angina (chest pain) due to reduced blood flow to the heart, musculoskeletal strain, or complications of heart failure, such as pleural effusion or edema. The effective management of acute pain and discomfort in heart failure patients is essential for improving their overall well-being, promoting rest and recovery, and enhancing their quality of life. By implementing appropriate interventions, healthcare professionals, including nurses, can help alleviate pain and provide comfort to patients experiencing acute episodes or ongoing discomfort.

1. Assess patient pain for intensity using a pain rating scale, location, and precipitating factors. To identify intensity, precipitating factors, and location to assist in accurate diagnosis.

2. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation.

3. Assess the response to medications every 5 minutes Assessing response determines the effectiveness of medication and whether further interventions are required.

4. Administer or assist with self-administration of vasodilators, as ordered. The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload, decreasing its workload.

5. Provide comfort measures. To provide non-pharmacological pain management.

6. Establish a quiet environment. A quiet environment reduces the energy demands on the patient.

7. Elevate the head of the bed. Elevation improves chest expansion and oxygenation.

8. Teach patient relaxation techniques and how to use them to reduce stress. Anginal pain is often precipitated by emotional stress that can be relieved by non-pharmacological measures such as relaxation .

9. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction . In some cases, chest pain may be more serious than stable angina. The patient needs to understand the differences to seek emergency care in a timely fashion.

Please visit Acute Pain Nursing Care Plan and Management for a more detailed interventions on the management of pain .

Promoting adequate tissue perfusion and effectively managing decreased cardiac tissue perfusion are crucial aspects of caring for patients with heart failure. Optimal tissue perfusion is vital for delivering oxygen and nutrients to the body’s organs and tissues, ensuring their proper function and health. Inadequate tissue perfusion in heart failure patients can result in various complications and symptoms, including fatigue, dizziness, reduced exercise tolerance, organ dysfunction, and impaired healing. Nurses play a pivotal role in promoting adequate tissue perfusion and managing decreased cardiac tissue perfusion in patients with heart failure. They collaborate closely with the healthcare team to develop individualized care plans tailored to each patient’s specific needs.

2. Monitor vital signs, especially pulse and blood pressure every 15 minutes or more frequently if unstable. Watch out for any reduction greater than 20 mm Hg over the patient’s baseline or related changes such as dizziness and changes in mental status. A major side effect of the medical management of heart failure is hypotension which can also result from the disease.

3. Assess the extremities for color, temperature, capillary refill, pulse presence, and amplitude. Signs of peripheral vasoconstriction due to sympathetic nervous system compensation include pallor, coolness, delayed capillary refill time (more than 2 seconds), and decreased pulse amplitude. The presence of edema in the extremities may be observed due to fluid overload.

4. Assess cardiac and circulatory status. This assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion.

5. Assess changes in mental status such as anxiety, memory loss, confusion, depression, restlessness, lethargy, stupor, and coma. This may signal reduced cerebral perfusion and decreased oxygen level.

6. Assess the response to medications every 5 minutes. Assessing response determines the effectiveness of medication and whether further interventions are required.

7. Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1, LDH-2, troponin, and myoglobin ordered by the physician. These enzymes elevate in the presence of myocardial infarction at differing times and assist in ruling out a myocardial infarction as the cause of chest pain.

8. Monitor cardiac rhythms on patient monitor and results of 12 lead ECG. Notes abnormal tracings that would indicate ischemia.

9. Administer or assist with self-administration of vasodilators, as ordered. The vasodilator nitroglycerin enhances blood flow to the myocardium. It reduces the amount of blood returning to the heart, decreasing preload, decreasing its workload.

10. Give beta-blockers as ordered. Beta-blockers decrease oxygen consumption by the myocardium and are given to prevent subsequent angina episodes.

11. Establish a quiet environment. A quiet environment reduces the energy demands on the patient.

12. Elevate the head of the bed. Elevation improves chest expansion and oxygenation.

13. Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered. Oxygenation increases the amount of oxygen circulating in the blood and, therefore, increases the amount of available oxygen to the myocardium, decreasing myocardial ischemia and pain.

14. Teach the patient relaxation techniques and how to use them to reduce stress. Anginal pain is often precipitated by emotional stress that can be relieved by non-pharmacological measures such as relaxation.

15. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction. In some cases, chest pain may be more serious than stable angina. The patient needs to understand the differences to seek emergency care in a timely fashion.

16. Reposition the patient every 2 hours To prevent bedsores

17. Instruct patient on eating small frequent feedings To prevent heartburn and acid indigestion

Nursing interventions for heart failure nutrition include educating patients about a low-sodium diet, monitoring adherence, involving family support, collaborating with a dietitian, and evaluating the patient’s response.

1. Assess the patient’s ability to comply with the recommended dietary sodium restriction and consider individual preferences, cultural food patterns, and nutritional needs when designing the diet plan. Each patient has unique dietary preferences, cultural food patterns, and nutritional needs. Assessing the patient’s ability to comply with the recommended sodium restriction allows for the development of a personalized diet plan. Collaborating with the patient helps strike a balance between sodium restriction and the patient’s ability to adhere to the prescribed diet, ensuring nutritional adequacy and promoting dietary compliance .

2. Educate the patient about the importance of following a low-sodium diet, typically no more than 2 g/day, to reduce fluid retention and symptoms of peripheral and pulmonary congestion. Educating the patient about the benefits of a low-sodium diet is crucial in managing heart failure. A low-sodium diet helps reduce fluid retention and alleviate symptoms associated with congestion. Providing information about sodium restriction empowers the patient to make dietary choices that support fluid balance and decrease myocardial workload.

3. Monitor the patient’s adherence to the low-sodium diet and assess for dietary indiscretions that may exacerbate heart failure symptoms. Regular monitoring of the patient’s adherence to the low-sodium diet is essential for optimizing heart failure management. Assessing for dietary indiscretions helps identify any deviations from the prescribed diet that may lead to severe exacerbations of heart failure symptoms. Early identification of nonadherence allows for interventions to reinforce the importance of the diet and prevent complications requiring hospitalization.

4. Involve family members in supporting the patient’s adherence to the low-sodium diet and encourage their participation in following the diet as well. Family support plays a significant role in helping patients adhere to a low-sodium diet. Involving family members and encouraging their participation in following the diet fosters a supportive environment for the patient. Studies have shown that patients whose family members also adhere to the low-sodium diet have better adherence themselves. Engaging family members in the patient’s dietary management improves outcomes and enhances the patient’s ability to adhere to the prescribed dietary restrictions.

5. Collaborate with a dietitian or nutritionist to provide comprehensive nutritional guidance and support for the patient. Collaboration with a dietitian or nutritionist can provide specialized expertise in developing and implementing a low-sodium diet plan for patients with heart failure. Collaboration allows for comprehensive nutritional guidance and support tailored to the patient’s specific needs. It ensures that the diet plan is nutritionally balanced, promotes dietary compliance, and supports overall heart failure management.

6. Evaluate the patient’s response to the low-sodium diet, including the resolution of symptoms, weight management, and overall improvement in heart failure status. Regular evaluation of the patient’s response to the low-sodium diet helps assess the effectiveness of dietary interventions in managing heart failure. Monitoring symptom resolution, weight changes, and overall improvement in heart failure status provides valuable feedback on the impact of the diet plan.

Maintaining skin integrity is a critical aspect of care for patients with heart failure. Heart failure can lead to various physiological changes and complications that can impact the health and integrity of the skin. Maintaining skin integrity in heart failure patients is essential to prevent complications such as pressure ulcers, skin breakdown, and infections. Healthy skin serves as a protective barrier against pathogens, and its integrity plays a vital role in the overall well-being of patients. Nursing interventions focus on promoting skin hygiene, implementing pressure relief strategies, providing wound care as needed, and educating patients and caregivers on skin care practices.

1. Inspect skin, noting skeletal prominences, presence of edema, areas of altered circulation, or obesity and/or emaciation. Skin is at risk because of impaired peripheral circulation, physical immobility, and alterations in nutritional status.

2. Check the fit of shoes and slippers and change as needed. Dependent edema may cause shoes to fit poorly, increasing the risk of pressure and skin breakdown on the feet.

3. Provide gentle massage around reddened or blanched areas. Improves blood flow, minimizing tissue hypoxia. Note: Direct massage of the compromised area may cause tissue injury.

4. Encourage frequent position changes and assist with active and passive range of motion (ROM) exercises. Reduces pressure on tissues, improves circulation, and reduces time in any area is deprived of full blood flow.

5. Provide frequent skincare: minimize contact with moisture and excretions. Excessive dryness or moisture damages skin and hastens breakdown.

6. Avoid intramuscular route for medication. Interstitial edema and impaired circulation impede drug absorption and predispose to tissue breakdown and development of infection.

7. Provide alternating pressure, egg-crate mattress, sheepskin elbow, and heel protectors. Reduces pressure on the skin, and may improve circulation.

Managing decreased tolerance to activity and fatigue in congestive heart failure is important to improve the patient’s quality of life and overall well-being. For patients with other conditions (such as arthritis ) and a longer duration of heart failure, it can be challenging to adhere to exercise training, which is vital for them to derive benefits from it. Temporary bed rest may be necessary if there is an acute illness that worsens heart failure symptoms or requires hospitalization. However, in all other cases, it is important to encourage some form of daily physical activity. Exercise training offers numerous benefits to heart failure patients, such as enhanced functional capacity, reduced dyspnea, and improved quality of life (Georgantas, Dimopoulos, Tasoulis, et al., 2014).

1. Check vital signs before and immediately after activity, especially if the patient receives vasodilators, diuretics, or beta-blockers. Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.

2. Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, and pallor. Compromised myocardium and inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating weakness and fatigue.

3. Assess for other causes of fatigue (treatments, pain, medications). Medications such as beta-blockers, tranquilizers, and sedatives can cause fatigue as a side effect. Pain and stressful procedures can also diminish the patient’s energy can cause fatigue.

4. Identify factors that could affect the desired level of activity and motivation . Age, pain, breathing problems, impaired visual acuity, hearing problems, functional decline, etc., are all factors that could hinder interventions from improving activity tolerance . Other factors unrelated to heart failure could affect the client’s participation in interventions to improve activity tolerance (Chew et al., 2019). Fatigue affects both the client’s actual and perceived ability to participate in activities.

5. Monitor and evaluate the patient’s response to activities. Regular monitoring of vital signs and oxygen saturation levels is crucial before, during, and after physical activity to ensure they remain within the desired range. The heart rate should return to baseline within 3 minutes after activity. Moderate continuous training, recommended by the Heart Failure Association Guidelines, is safe, effective, and well-tolerated by patients with heart failure. Adjusting the intensity, duration, and frequency of exercise based on the patient’s response is essential, both in the hospital and at home. Adherence to exercise training may be challenging for some patients, and referral to a cardiac rehabilitation program can provide additional support, especially for newly diagnosed patients with heart failure or those requiring extra guidance. If the patient is hospitalized, monitor vital signs and oxygen saturation levels before, during, and after physical activity to ensure they remain within the desired range. If the patient is at home, assess the degree of fatigue experienced after activity. Monitoring the patient’s response helps evaluate tolerance and adjust the intensity, duration, and frequency of activity accordingly.

6. Consider the use of the 6-minute walk test (6MWT) to determine the patient’s physical ability. 6MWT is an exercise test that entails measuring the distance walked over a span of 6 minutes (Enright, 2003). It helps gauge the patient’s cardiopulmonary response . More information about the 6MWT can be found here .

7. Assist in identifying and overcoming barriers to physical activity. Identify barriers that may hinder the patient’s ability to engage in physical activity and discuss strategies to overcome them. For example, suggesting sitting while performing tasks like chopping or peeling vegetables can help conserve energy. By addressing barriers, patients are more likely to incorporate physical activity into their daily routine.

8. Encourage daily physical activity. Patients with heart failure often experience reduced physical activity, leading to physical deconditioning and worsening symptoms. Encouraging daily physical activity helps improve exercise tolerance, functional capacity, and quality of life in patients with heart failure.

9. Collaborate with the primary provider and patient to develop a personalized exercise schedule. A collaborative approach involving the primary provider, nurse, and patient is essential in developing an exercise schedule that promotes pacing and prioritization of activities. This helps ensure that activities are balanced with periods of rest and prevents excessive energy consumption.

10. Provide guidelines for safe physical activity. Start slow and low. Before engaging in physical activity, the patient should be given guidelines to follow, such as starting with low-impact activities like walking , incorporating warm-up and cool-down periods, avoiding extreme weather conditions, waiting 2 hours after meals before exercising, and ensuring the ability to talk during activity. These guidelines promote safety and prevent complications during exercise.

11. Evaluate accelerating activity intolerance. May denote increasing cardiac decompensation rather than overactivity. Three factors that affect the risk of exercise include age, heart disease presence, and exercise intensity (Piña et al., 2003). Sudden cardiac death during exercise is rare in apparently healthy individuals. Individuals with cardiac disease seem to be at a greater risk for sudden cardiac arrest during vigorous exercise (such as jogging) than are healthy individuals (Fletcher et al., 2001). Reduced physical activity in heart failure (HF) patients leads to physical deconditioning and worsens symptoms. It is important to encourage daily physical activity while considering the patient’s limitations and risks. Exercise training has numerous benefits, including increased functional capacity, decreased dyspnea, and improved quality of life.

12. Promote adherence to exercise training. Adherence to exercise training is crucial for patients to benefit from it. Patients may face challenges due to comorbidities or the duration of HF. Referral to a cardiac rehabilitation program can provide supervised exercise sessions, structured environments, educational support, regular encouragement, and interpersonal contact.

13. Assist with self-care activities as necessary. Encourage independence within prescribed limits. Assisting with ADLs ensure that the patient’s need is met while reducing cardiac workload. As much as possible and as tolerated by the patient, involve them in promoting a sense of control and reducing helplessness.

14. Slow the pace of care and provide adequate rest before and after periods of exertion (e.g., bathing, eating, exercise). Allow the patient extra time to carry out physical tasks, especially on geriatric clients. Older patients are more vulnerable to falls and injuries due to decreased muscle strength, reduced balance, etc.

15. Organize nursing care activities to allow rest periods. Intersperse activity periods with rest periods by developing a schedule that promotes pacing and prioritizes activities to meet the patient’s personal care needs without undue myocardial stress and excessive oxygen demand (Cattadori et al., 2018; Piña et al., 2003). Grouping nursing care allows adequate time for the patient to recharge.

16. Implement a graded cardiac rehabilitation program. Strengthens and improves cardiac function under stress if cardiac dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial workload and oxygen consumption. Cardiac rehabilitation offers an effective model of care for older patients with heart failure (Austin et al., 2005). The potential benefit of increasing exercise performance by increasing training load from moderate to higher doses of exercise should be weighed against the lack of an improvement in cardiac vagal modulation and the possible increase in the risk of adverse events (Volterrani & Iellamo, 2016).

17. Adjust the client’s daily activities and reduce the intensity of the level. Discontinue activities that cause undesired physiological and psychological changes . It prevents straining and overexertion, which may aggravate symptoms. Stop all activity if severe shortness of breath, pain, or dizziness develops. Additionally, instruct the patient or significant other to recognize the signs of overexertion. One way to ensure the patient is not overexerting during physical ability is if they can talk during the routine; if they cannot do so, decrease the intensity of activity.

18. Encourage patient to have adequate bed rest and sleep; provide a calm and quiet environment. It relaxes the body and promotes comfort. Temporary bed rest should also be implemented during an acute exacerbation of heart failure symptoms.

19. Initiate interventions and safeguards to promote safety and prevent risk for injury during activity. Interventions include:

• Assist the patient during ambulation, if necessary.
• Ascertain the patient’s ability to stand and move about and degree of assistance needed or use of movement aids or equipment.
• Instruct or demonstrate physical activities that may be unfamiliar with the patient.
• Start with warm-up activity and end with cool-down activities.
• Avoid performing physical activities outside extreme temperatures or during humid weather.
• Wait 2 hours after eating a meal before performing a physical activity.

20. Encourage the client to maintain a positive attitude; provide evidence of daily or weekly progress. It helps enhance the patient’s sense of well-being and raises the patient’s motivation and morale. Motivation is necessary for patients with HF who are attempting to become more physically active but may not be sufficient to initiate physical activity. In addition to a high level of motivation to be physically active, patients with HF must have a high degree of self-efficacy (Klompstra et al., 2018). Provide a positive atmosphere during the exercise regimen to help minimize patient frustration.

Patients with heart failure may display signs and symptoms of anxiety. Alongside psychosocial factors contributing to anxiety, there are also physiological compensatory mechanisms involved, such as the activation of neurohormones, including catecholamines (Chapa et al., 2014). Anxiety stems from factors like the fear of shocks, role adjustments, and concerns about the patient’s ability to perform daily activities. When the patient shows symptoms of anxiety, the nurse takes measures to facilitate physical comfort and provide psychological support.

1. Assess for restlessness and anxiety as potential indicators of hypoxia from pulmonary congestion. Restlessness and anxiety may suggest inadequate oxygenation, which can occur in HF due to pulmonary congestion. Prompt recognition of these signs allows for appropriate interventions to improve oxygenation.

2. Promote physical comfort and provide psychological support. When the patient exhibits anxiety, it is essential for the nurse to prioritize the patient’s physical comfort and provide psychological support. Creating a calming environment and ensuring the patient feels safe and secure can help reduce anxiety levels. Physical comfort measures, such as allowing the patient to sit in a recliner, can enhance relaxation and decrease anxiety.

3. Assess physical reactions to anxiety. Anxiety also plays a role in somatoform disorders, characterized by physical symptoms such as pain, nausea, weakness, or dizziness that have no apparent physical cause.

4. Administer oxygen during acute events. During acute episodes of anxiety, administering oxygen can help diminish the work of breathing and increase the patient’s comfort. Adequate oxygenation contributes to a sense of ease and relaxation.

5. Validate observations by asking the patient, “Are you feeling anxious now?” Anxiety is a highly individualized, physical, and psychological response to internal or external life events.

6. Recognize awareness of the patient’s anxiety. Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of those feelings.

7. Interact with patients in a calm, peaceful manner. This approach may help decrease anxiety so that patient’s cardiac work is also decreased.

8. Encourage the patient to express fears, feelings regarding the condition. Recognizing one’s feelings allows communication, thus decreasing fear.

9. Identify present and past measures that the patient uses to cope with fear. This information helps determine the effectiveness of coping strategies practiced by the patient.

10. Assess for factors contributing to a sense of powerlessness. Identifying the related factors with powerlessness can benefit in recognizing potential causes and building a collaborative plan of care.

11. Assess for feelings of apathy, hopelessness, and depression. These moods may be an element of powerlessness.

12. Evaluate the patient’s decision-making competence. Powerlessness is the feeling that one has lost the implicit power to control their own interests.

13. Know situations/interactions that may add to the patient’s sense of powerlessness. Healthcare providers must recognize the patient’s right to refuse certain procedures. Some routines are done on patients without their consent fostering a sense of powerlessness.

14. Appraise the impact of powerlessness on the patient’s physical condition (e.g., appearance, oral intake, hygiene, sleep habits). Individuals may seem as though they are powerless to establish basic aspects of life and self-care activities.

15. Assess the role of illness plays in the patient’s sense of powerlessness. The dilemma about events, duration, course of illness, prognosis, and dependence on others for guidance and treatments can contribute to powerlessness.

16. Evaluate the results of the information given on the patient’s feelings and behavior. Patients facing powerlessness may overlook information. Too much information may overwhelm the patient and add to feelings of powerlessness. A patient simply experiencing a knowledge deficit may be mobilized to act in their own best interest after the information is presented and options are explored. The act of providing information about heart failure may strengthen a patient’s sense of independence.

17. Encourage a calm and quiet environment. This intervention avoids or decreases the sensory overload that may cause fear.

18. Familiarize patients with the environment and new experiences or people as needed. Awareness of the environment promotes comfort and may decrease anxiety experienced by the patient. Anxiety may intensify to a panic level if the patient feels threatened and unable to control environmental stimuli. A decrease in anxiety will also mean that patient’s cardiac work is also decreased.

19. Administer oxygen during the acute stage. Oxygen therapy diminishes the work of breathing and increases comfort.

20. When the patient displays anxiety, promote physical comfort and psychological support. A family member’s presence may provide reassurance; pet visitation or animal-assisted therapy can also be helpful.

21. Converse using simple language and brief statements. When experiencing moderate to severe anxiety , patients may not understand anything more than simple, clear, and brief instructions.

22. When the patient is comfortable, teach ways to control anxiety and avoid anxiety-provoking situations. Anxiety may intensify to a panic state with excessive conversation, noise, and equipment around the patient. Increasing anxiety may become frightening to the patient and others.

23. Assist in identifying factors that contribute to anxiety. Talking about anxiety-producing situations and anxious feelings can help the patient perceive the situation realistically and recognize anxiety-related factors.

24. Help patient determine precipitants of anxiety that may indicate interventions. Obtaining insight allows the patient to reevaluate the threat or identify new ways to deal with it.

25. Screen for depression, which often accompanies or results from anxiety. Symptoms of depression and anxiety are present in about one-third of patients with heart failure. Studies found evidence confirming “markedly higher” rates of depression and anxiety disorders among patients with heart failure compared to the general population.

26. Allow the patient to talk about anxious feelings and examine anxiety-provoking situations if they are identifiable. Talking about anxiety-producing situations and anxious feelings can help the patient perceive the situation realistically and recognize anxiety-related factors.

27. Assist the patient in developing new anxiety-reducing skills (e.g., relaxation, deep breathing, positive visualization, and reassuring self-statements). Discovering new coping methods provides the patient with a variety of ways to manage anxiety.

28. Avoid unnecessary reassurance; this may increase undue worry. Reassurance is not helpful for the anxious individual.

29. Intervene when possible to eliminate sources of anxiety. Anxiety is a normal response to actual or perceived danger; the response will stop if the threat is eliminated.

30. Explain all activities, procedures, and issues that involve the patient; use non-medical terms and calm, slow speech. Do this in advance of procedures when possible, and validate the patient’s understanding. With preadmission patient education, patients experience less anxiety and emotional distress and have increased coping skills because they know what to expect. Uncertainty and lack of predictability contribute to anxiety.

31. Educate patient and family about the symptoms of anxiety. If the patient and family can identify anxious responses, they can intervene earlier than otherwise.

32. Teach patients to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of conflict, or outcome of the procedure. The use of guided imagery has been useful for reducing anxiety.

33. Maintain a relaxed and accepting demeanor while communicating with the patient. The patient’s feeling of stability increases in a peaceful and non-threatening environment.

34. Use simple language and easy-to-understand statements regarding diagnostic procedures and treatment regimens. Simple, clear, and brief instructions are important for the patient to understand any explanations during excessive fear.

35. Provide patients and significant others with emotional support. The support system from the family and other significant others is important for the patient in decreasing their level of fear.

36. Allow the patient to have rest periods. Relaxation improves the ability to cope. The nurse needs to pace activities, especially for older adults, to conserve the patient’s energy.

37. Listen actively to patients often. This approach creates a supportive environment and sends a message of caring.

38. Encourage the patient to identify strengths. This will aid the patient in recognizing inner strengths.

39. Provide the patient with decision-making opportunities with increasing frequency and significance. This approach enhances the patient’s independence.

40. Help the patient in reexamining negative perceptions of the situation. The patient may have their own perceptions that are unrealistic for the situation.

41. Provide encouragement and praise while identifying the patient’s progress. This approach creates a supportive environment and sends a message of caring.

42. Assist the patient in differentiating between factors that can be controlled and those that cannot. The patient may have their own perceptions that are unrealistic for the situation.

43. Avoid using coercive power when approaching the patient. This approach may increase the patient’s feelings of powerlessness and result in decreased self-esteem .

44. Eliminate the unpredictability of events by allowing adequate preparation for tests or procedures. Information in advance of a procedure can provide the patient with a sense of control.

45. Support in planning and creating a timetable to manage increased responsibility in the future. Use of realistic short-term goals for resuming aspects of self-care foster confidence in one’s abilities.

46. Provide safety measures within the home when indicated (e.g., alarm system, safety devices in showers, bathtubs). The patient’s fear will not be reduced or resolved if the home environment is unsafe.

Treating heart failure involves intricate therapeutic regimens that necessitate substantial lifestyle adjustments for both the patient and their family. Hospital readmissions are frequently caused by noncompliance with prescribed diet, fluid restrictions, and medications. Furthermore, inadequate coordination of care and insufficient clinical follow-up contribute to unfavorable outcomes (Albert et al., 2015). Nurses play a crucial role in managing episodes of acute decompensated HF and creating a comprehensive teaching and discharge plan. This plan aims to prevent hospital readmissions and enhance the patient’s quality of life.

1. Discuss normal heart function. Include information regarding the patient’s variance from normal function. Explain the difference between heart attack and HF. Knowledge of disease processes and expectations can facilitate adherence to the prescribed treatment regimens.

2. Reinforce treatment rationale. Include SOs in teaching as appropriate, especially for complicated regimens such as dobutamine infusion home therapy when the patient does not respond to customary combination therapy or cannot be weaned from dobutamine or those awaiting a heart transplant. Patients may believe it is acceptable to alter the postdischarge regimen when feeling well and symptom-free or when feeling below par, which can increase the risk of exacerbating symptoms. Understanding of regimen, medications, and restrictions may augment cooperation with control of symptoms. Home IV therapy requires a significant commitment by caregivers to troubleshoot infusion pumps, change the dressing for peripherally inserted central catheter (PICC) line, monitor I&O and signs and symptoms of HF.

3. Encourage developing a regular home exercise program, and provide guidelines for sexual activity. Promotes maintenance of muscle tone and organ function for the overall sense of well-being. Changing sexual habits may be difficult (sex in the morning when well-rested, patient on top, inclusion of other physical expressions of affection) but provides an opportunity for continuing a satisfying sexual relationship.

4. Discuss the importance of being as active as possible without becoming exhausted and rest between activities. Excessive physical activity or overexertion can further weaken the heart, exacerbating failure, and necessitates adjustment of exercise program.

5. Discuss the importance of sodium limitation. Provide a list of the sodium content of common foods that are to be avoided and limited. Encourage reading of labels on food and drug packages. Dietary intake of sodium of more than 3 grams per day can offset the effect of diuretics. The most common source of sodium is table salt and obviously salty foods, although canned soups, luncheon meats, and dairy products also may contain high sodium levels.

6. Refer to a dietitian for counseling specific to individual dietary customs. Identifies dietary needs, especially in the presence of nausea, vomiting , and resulting wasting syndrome (cardiac cachexia). Eating six small meals and using liquid dietary supplements and vitamin supplements can limit inappropriate weight loss.

7. Review medications, purpose, and side effects. Provide both oral and written instructions. Understanding therapeutic needs and the importance of prompt reporting of side effects can prevent the occurrence of drug-related complications. Anxiety may block comprehension of input or details, and patient/ SO may refer to written material later to refresh memory.

8. Recommend taking diuretic early in the morning. Provides adequate time for drug effects before bedtime to prevent interruption of sleep.

9. Instruct and receive return demonstration of ability to take and record daily pulse and blood pressure and when to notify health care provider: parameters above or below preset rate, changes in rhythm, and regularity. Promotes self-monitoring of drug effects. Early detection of changes allows for timely intervention and may prevent complications, such as digitalis toxicity .

10. Explain and discuss the patient’s role in controlling risk factors (smoking, unhealthy diet) and precipitating or aggravating factors (high-salt diet, inactivity, overexertion, exposure to extremes in temperature). It adds to the body of knowledge and permits the patient to make informed decisions regarding condition control and prevention of complications. Smoking potentiates vasoconstriction; sodium intake promotes water retention or edema formation; improper balance between activity and rest and exposure to temperature extremes may result in exhaustion and/or increased myocardial workload and increased risk of respiratory infections. Alcohol can depress cardiac contractility. Limitation of alcohol use to social occasions or a maximum of 1 drink per day may be tolerated unless cardiomyopathy is alcohol-induced (requiring complete abstinence).

11. Review signs and symptoms that require immediate medical attention: rapid and significant weight gain, edema, shortness of breath, increased fatigue, cough, hemoptysis, fever. Self-monitoring increases patient responsibility in health maintenance and aids in the prevention of complications, e.g., pulmonary edema, pneumonia. Weight gain of more than 3 lb in a week requires medical adjustment of diuretic therapy. Note: Patient should weigh self daily in morning without clothing, after voiding, and before eating.

12. Provide opportunities for patients and SO to ask questions, discuss concerns, and make necessary lifestyle changes. HF’s chronicity and debilitating nature often exhaust both the patient’s and significant other’s coping abilities and supportive capacity, leading to depression.

13. Discuss general health risks (such as infection), recommending avoidance of crowds and individuals with respiratory infections, obtaining yearly influenza immunization and one-time pneumonia immunization. This population is at increased risk for infection because of circulatory compromise.

14. Stress importance of reporting signs and symptoms of digitalis toxicity: development of gastrointestinal (GI) and visual disturbances, changes in pulse rate and rhythm, worsening of heart failure. Early recognition of developing complications and involvement of healthcare providers may prevent toxicity.

15. Identify community resources and support groups and visiting home health nurses as indicated. Encourage participation in an outpatient cardiac rehabilitation program. May need additional assistance with self-monitoring, home management, especially when HF is progressive.

16. Discuss the importance of advance directives and communicating plans and wishes to family and primary care providers. Up to 50% of all deaths from heart failure are sudden, with many occurring at home, possibly without significant worsening of symptoms. If the patient chooses to refuse life-support measures, an alternative contact person (rather than 911) should be designated, should cardiac arrest occur.

17. Assess the patient with underlying coronary artery disease for consideration of coronary artery revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass surgery. Patients with heart failure and underlying coronary artery disease may benefit from coronary artery revascularization procedures. Assessing the patient’s eligibility and suitability for PCI or coronary artery bypass surgery helps determine the appropriate surgical approach to improve coronary blood flow and potentially enhance ventricular function.

18. Identify patients with severe left ventricular dysfunction at high risk for life-threatening dysrhythmias and consider the placement of an implantable cardioverter defibrillator (ICD). Patients with severe left ventricular dysfunction and a high risk of life-threatening dysrhythmias may benefit from an ICD. Identifying eligible candidates, typically those with an ejection fraction (EF) less than 35% and NYHA functional class II or III, helps prevent sudden cardiac death and extends survival. Collaboration with the healthcare team ensures appropriate selection and placement of the ICD device.

19. Evaluate patients who do not respond to standard therapy for cardiac resynchronization therapy (CRT) and consider the use of a biventricular pacemaker to treat electrical conduction defects. Patients with heart failure who do not improve with standard therapy may benefit from CRT. Identifying patients with a prolonged QRS duration on the electrocardiogram (ECG) indicating left bundle branch block helps identify those who may benefit from CRT. Placement of a pacing device with leads in the right atrium , right ventricle, and left ventricular cardiac vein synchronizes ventricular contractions, optimizing cardiac output, reducing mitral regurgitation, and improving overall ventricular function.

20. Monitor patients receiving ultrafiltration for severe fluid overload, especially those resistant to diuretic therapy. Ultrafiltration is an alternative intervention for patients with severe fluid overload who do not respond to diuretic therapy. Monitoring the patient’s output of filtration fluid, blood pressure, and hemoglobin levels helps assess volume status and response to ultrafiltration. Regular monitoring ensures patient safety and allows for adjustments in the filtration process as needed.

21. Consider referral for cardiac transplantation in patients with end-stage heart failure who are eligible for long-term survival. For patients with end-stage heart failure who have exhausted other treatment options, cardiac transplantation may be the best option for long-term survival. Referring eligible patients for consideration of transplantation ensures access to a potentially life-saving intervention. Collaboration with the healthcare team and transplant centers facilitates appropriate evaluation and selection of candidates.

22. Provide nursing surveillance for older male patients receiving diuretics to monitor for bladder distention caused by urethral obstruction from an enlarged prostate gland. Older male patients receiving diuretics may be at risk of bladder distention due to urethral obstruction from an enlarged prostate gland. Regular monitoring of urinary symptoms, such as urinary frequency, urgency, and signs of bladder fullness, helps detect potential complications. Nursing interventions, such as ultrasound scanning or palpation of the suprapubic area, aid in assessing bladder fullness and managing urinary issues in older patients with limited mobility .

23. Address the unique symptoms and challenges faced by older adults with heart failure, including atypical symptoms, decreased renal function, and mobility limitations. Older adults with heart failure may present with atypical symptoms, such as weakness and somnolence, instead of typical symptoms like shortness of breath. Assessing and addressing these symptoms helps ensure appropriate management. Additionally, older adults may have decreased renal function, affecting diuretic response, and limited mobility , which can exacerbate challenges related to urinary symptoms. Taking these factors into account during nursing care optimizing outcomes for older patients with heart failure.

For the expected patient outcomes , the following are evaluated:

• Demonstration of tolerance for increased activity.
• Maintenance of  fluid balance .
• Less anxiety.
• Decides soundly regarding care and treatment.
• Adherence to self-care regimen.

The nurse should provide education and involve the patient in the therapeutic regimen .

• Patient education . Teach the patient and their families about medication management, low-sodium diets, activity and exercise recommendations, smoking cessation, and learning to recognize the signs and symptoms of worsening HF.
• Encourage the patient and their families to ask questions so that information can be clarified and understanding enhanced.
• Cardiac output adequate for individual needs.
• Complications prevented/resolved.
• Optimum level of activity/functioning attained.
• Disease process/prognosis and therapeutic regimen understood.
• Plan in place to meet needs after discharge.

The following data should be documented appropriately:

• Assessment findings
• I&O fluid balance
• Degree o f fluid retention
• Results of laboratory tests and diagnostic studies.
• Response to interventions, teachings, and actions performed.
• Attainment or progress toward desired outcomes .

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other nursing care plans for cardiovascular system disorders:

• Angina Pectoris (Coronary Artery Disease)
• Cardiac Arrhythmia (Digitalis Toxicity)
• Cardiac Catheterization
• Cardiogenic Shock
• Congenital Heart Disease
• Decreased Cardiac Output & Cardiac Support
• Heart Failure
• Hypertension
• Hypovolemic Shock
• Impaired Tissue Perfusion & Ischemia
• Myocardial Infarction
• Pacemaker Therapy

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

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Recommended journals, books, and other interesting materials to help you learn more about heart failure nursing care plans and nursing diagnosis:

• Albert, N. M. (2012). Fluid management strategies in heart failure . Critical care nurse , 32 (2), 20-32.
• Albert, N., Trochelman, K., Li, J., & Lin, S. (2010). Signs and symptoms of heart failure: are you asking the right questions? . American Journal of Critical Care , 19 (5), 443-452.
• Alkhawam, H., Abo-Salem, E., Zaiem, F., Ampadu, J., Rahman, A., Sulaiman, S., … & Vittorio, T. J. (2019). Effect of digitalis level on readmission and mortality rate among heart failure reduced ejection fraction patients . Heart & Lung , 48 (1), 22-27.
• Allen, J. K., & Dennison, C. R. (2010). Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: systematic review . Journal of Cardiovascular Nursing , 25 (3), 207-220.
• Amin, A., Garcia Reeves, A. B., Li, X., Dhamane, A., Luo, X., Di Fusco, M., … & Keshishian, A. (2019). Effectiveness and safety of oral anticoagulants in older adults with non-valvular atrial fibrillation and heart failure . PloS one , 14 (3), e0213614.
• Austin, J., Williams, R., Ross, L., Moseley, L., & Hutchison, S. (2005). Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure . European Journal of Heart Failure , 7 (3), 411-417.
• Barrese, V., & Taglialatela, M. (2013). New advances in beta-blocker therapy in heart failure . Frontiers in physiology , 4 , 323.
• Bikdeli, B., Strait, K. M., Dharmarajan, K., Li, S. X., Mody, P., Partovian, C., … & Krumholz, H. M. (2015). Intravenous fluids in acute decompensated heart failure . JACC: Heart Failure , 3 (2), 127-133.
• Bocchi, E. A. (2001). Cardiomyoplasty for treatment of heart failure . European journal of heart failure , 3 (4), 403-406.
• Bolger, A. P., Coats, A. J., & Gatzoulis, M. A. (2003). Congenital heart disease: the original heart failure syndrome . European Heart Journal , 24 (10), 970-976.
• Brater, D. C. (2000). Pharmacology of diuretics . The American journal of the medical sciences , 319 (1), 38-50.
• Brennan, E. J. (2018). Chronic heart failure nursing: integrated multidisciplinary care . British Journal of Nursing , 27 (12), 681-688.
• Brunner, L. S. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (Vol. 1). Lippincott Williams & Wilkins.
• Butler, J., Young, J. B., Abraham, W. T., Bourge, R. C., Adams, K. F., Clare, R., … & ESCAPE Investigators. (2006). Beta -blocker use and outcomes among hospitalized heart failure patients . Journal of the American College of Cardiology , 47 (12), 2462-2469.
• Cattadori, G., Segurini, C., Picozzi, A., Padeletti, L., & Anzà, C. (2018). Exercise and heart failure: an update . ESC heart failure , 5 (2), 222-232.
• Chew, H. S. J., Sim, K. L. D., & Cao, X. (2019). Motivation, challenges and self-regulation in heart failure self-care: a theory-driven qualitative study . International journal of behavioral medicine , 26 (5), 474-485.
• Conti, C. R. (2011). Intravenous morphine and chest pain . Clinical cardiology , 34 (8), 464.
• Cowie, M. R., & Mendez, G. F. (2002). BNP and congestive heart failure . Progress in cardiovascular diseases , 44 (4), 293-321.
• De Bruyne, L. K. M. (2003). Mechanisms and management of diuretic resistance in congestive heart failure . Postgraduate medical journal , 79 (931), 268-271.
• De Jong, M. J., Chung, M. L., Wu, J. R., Riegel, B., Rayens, M. K., & Moser, D. K. (2011). Linkages between anxiety and outcomes in heart failure . Heart & Lung , 40 (5), 393-404.
• Drazner, M. H., Rame, J. E., & Dries, D. L. (2003). Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction . The American journal of medicine , 114 (6), 431-437.
• Elkayam, U., Akhter, M. W., Tummala, P., Khan, S., & Singh, H. (2002). Nesiritide: a new drug for the treatment of decompensated heart failure . Journal of cardiovascular pharmacology and therapeutics , 7 (3), 181-194.
• Ellison, D. H., & Felker, G. M. (2017). Diuretic treatment in heart failure . New England Journal of Medicine , 377 (20), 1964-1975.
• Enright, P. L. (2003). The six-minute walk test . Respiratory care , 48 (8), 783-785.
• Faris, R. F., Flather, M., Purcell, H., Poole‐Wilson, P. A., & Coats, A. J. (2012). Diuretics for heart failure . Cochrane Database of Systematic Reviews , (2).
• Felker, G. M., Ellison, D. H., Mullens, W., Cox, Z. L., & Testani, J. M. (2020). Diuretic therapy for patients with heart failure: JACC state-of-the-art review . Journal of the American College of Cardiology , 75 (10), 1178-1195.
• Fletcher, G. F., Balady, G. J., Amsterdam, E. A., Chaitman, B., Eckel, R., Fleg, J., … & Bazzarre, T. (2001). Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation , 104 (14), 1694-1740.
• Friederich, J. A., & Butterworth, J. F. (1995). Sodium nitroprusside: twenty years and counting . Anesthesia & Analgesia , 81 (1), 152-162.
• Gao, X., Peng, L., Adhikari, C. M., Lin, J., & Zuo, Z. (2007). Spironolactone reduced arrhythmia and maintained magnesium homeostasis in patients with congestive heart failure . Journal of cardiac failure , 13 (3), 170-177.
• Giordano, F. J. (2005). Oxygen, oxidative stress, hypoxia, and heart failure . The Journal of clinical investigation, 115(3), 500-508.
• Grady, K. L., Dracup, K., Kennedy, G., Moser, D. K., Piano, M., Stevenson, L. W., & Young, J. B. (2000). Team management of patients with heart failure: a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association . Circulation , 102 (19), 2443-2456.
• Haque, W. A., Boehmer, J., Clemson, B. S., Leuenberger, U. A., Silber, D. H., & Sinoway, L. I. (1996). Hemodynamic effects of supplemental oxygen administration in congestive heart failure . Journal of the American College of Cardiology , 27 (2), 353-357.
• Herman, L. L., & Tivakaran, V. S. (2017). Hydralazine .
• Hinkle, J. L., & KH, C. (2017). Brunner & Suddarth’s textbook of medical‑surgical nursing. Vol. 1.
• Holme, M. R., & Sharman, T. (2020). Sodium nitroprusside .
• Jaarsma, T., Strömberg, A., De Geest, S., Fridlund, B., Heikkila, J., Mårtensson, J., … & Thompson, D. R. (2006). Heart failure management programmes in Europe . European Journal of Cardiovascular Nursing , 5 (3), 197-205.
• Jacobs, M. (1984). Mechanism of action of hydralazine on vascular smooth muscle . Biochemical pharmacology , 33 (18), 2915-2919.
• Joynt, K. E., Whellan, D. J., & O’connor, C. M. (2004). Why is depression bad for the failing heart? A review of the mechanistic relationship between depression and heart failure . Journal of cardiac failure , 10 (3), 258-271.
• Jurgens, C. Y., Goodlin, S., Dolansky, M., Ahmed, A., Fonarow, G. C., Boxer, R., … & Rich, M. W. (2015). Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America . Circulation: Heart Failure , 8 (3), 655-687.
• Kemp, C. D., & Conte, J. V. (2012). The pathophysiology of heart failure . Cardiovascular Pathology , 21 (5), 365-371.
• Kim, W., & Kim, E. J. (2018). Heart failure as a risk factor for stroke . Journal of stroke , 20 (1), 33.
• Klompstra, L., Jaarsma, T., & Strömberg, A. (2018). Self-efficacy mediates the relationship between motivation and physical activity in patients with heart failure . The Journal of cardiovascular nursing , 33 (3), 211.
• Krämer, B. K., Schweda, F., & Riegger, G. A. (1999). Diuretic treatment and diuretic resistance in heart failure . The American journal of medicine , 106 (1), 90-96.
• Leier, C. V., & Chatterjee, K. (2007). The physical examination in heart failure—Part I . Congestive Heart Failure , 13 (1), 41-47.
• Levy, P., Compton, S., Welch, R., Delgado, G., Jennett, A., Penugonda, N., … & Zalenski, R. (2007). Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis . Annals of emergency medicine , 50 (2), 144-152.
• Lewis, P. A., Ward, D. A., & Courtney, M. D. (2009). The intra-aortic balloon pump in heart failure management: implications for nursing practice . Australian critical care , 22 (3), 125-131.
• Maisel, W. H., & Stevenson, L. W. (2003). Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy . The American journal of cardiology , 91 (6), 2-8.
• Masip, J., Gayà, M., Páez, J., Betbesé, A., Vecilla, F., Manresa, R., & Ruíz, P. (2012). Pulse oximetry in the diagnosis of acute heart failure . Revista Española de Cardiología (English Edition) , 65 (10), 879-884.
• Milo-Cotter, O., Cotter, G., Kaluski, E., Rund, M. M., Felker, G. M., Adams, K. F., … & Weatherley, B. D. (2009). Rapid Clinical Assessment of Patients with Acute Heart Failure: First Blood Pressure and Oxygen Saturation–Is That All We Need ? . Cardiology , 114 (1), 75-82.
• Mullens, W., Abrahams, Z., Francis, G. S., Skouri, H. N., Starling, R. C., Young, J. B., … & Tang, W. W. (2008). Sodium nitroprusside for advanced low-output heart failure . Journal of the American College of Cardiology , 52 (3), 200-207.
• Nicholson, C. (2007). Heart failure: A clinical nursing handbook (Vol. 31). John Wiley & Sons.
• Nyolczas, N., Dekany, M., Muk, B., & Szabo, B. (2017). Combination of hydralazine and isosorbide-dinitrate in the treatment of patients with heart failure with reduced ejection fraction . Heart Failure: From Research to Clinical Practice , 31-45.
• Oh, S. W., & Han, S. Y. (2015). Loop diuretics in clinical practice . Electrolytes & Blood Pressure , 13 (1), 17-21.
• Pereira, J. D. M. V., Cavalcanti, A. C. D., Lopes, M. V. D. O., Silva, V. G. D., Souza, R. O. D., & Gonçalves, L. C. (2015). Accuracy in inference of nursing diagnoses in heart failure patients . Revista brasileira de enfermagem , 68 , 690-696.
• Picano, E., Gargani, L., & Gheorghiade, M. (2010). Why, when, and how to assess pulmonary congestion in heart failure: pathophysiological, clinical, and methodological implications . Heart failure reviews , 15 (1), 63-72.
• Piña, I. L., Apstein, C. S., Balady, G. J., Belardinelli, R., Chaitman, B. R., Duscha, B. D., … & Sullivan, M. J. (2003). Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention . Circulation , 107 (8), 1210-1225.
• Platz, E., Merz, A. A., Jhund, P. S., Vazir, A., Campbell, R., & McMurray, J. J. (2017). Dynamic changes and prognostic value of pulmonary congestion by lung ultrasound in acute and chronic heart failure: a systematic review . European journal of heart failure , 19 (9), 1154-1163.
• Qamer, S. Z., Malik, A., Bayoumi, E., Lam, P. H., Singh, S., Packer, M., … & Ahmed, A. (2019). Digoxin use and outcomes in patients with heart failure with reduced ejection fraction . The American journal of medicine , 132 (11), 1311-1319.
• Redeker, N. S., Adams, L., Berkowitz, R., Blank, L., Freudenberger, R., Gilbert, M., … & Rapoport, D. (2012). Nocturia, sleep and daytime function in stable heart failure. Journal of Cardiac Failure , 18 (7), 569-575 .
• Reid, M. B., & Cottrell, D. (2005). Nursing care of patients receiving: Intra-aortic balloon counterpulsation. Critical care nurse , 25 (5), 40-49.
• Rogers, C., & Bush, N. (2015). Heart failure: Pathophysiology, diagnosis, medical treatment guidelines, and nursing management . The Nursing Clinics of North America , 50 (4), 787-799.
• Rutledge, T., Reis, V. A., Linke, S. E., Greenberg, B. H., & Mills, P. J. (2006). Depression in heart failure: a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes . Journal of the American college of Cardiology , 48 (8), 1527-1537.
• Scott, L. D., Setter-Kline, K., & Britton, A. S. (2004). The effects of nursing interventions to enhance mental health and quality of life among individuals with heart failure . Applied Nursing Research , 17 (4), 248-256.
• Serber, S. L., Rinsky, B., Kumar, R., Macey, P. M., Fonarow, G. C., & Harper, R. M. (2014). Cerebral blood flow velocity and vasomotor reactivity during autonomic challenges in heart failure . Nursing research , 63 (3), 194.
• Sica, D. A., Carter, B., Cushman, W., & Hamm, L. (2011). Thiazide and loop diuretics . The journal of clinical hypertension , 13 (9), 639-643.
• Volterrani, M., & Iellamo, F. (2016). Cardiac Rehabilitation in patients with heart failure: New perspectives in exercise training . Cardiac failure review , 2 (1), 63.
• Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey Jr, D. E., Colvin, M. M., … & Westlake, C. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America . Journal of the American College of Cardiology , 70 (6), 776-803.
• Zhao, X., Zhang, D. Q., Song, R., & Zhang, G. (2020). Nesiritide in patients with acute myocardial infarction and heart failure: a meta-analysis . Journal of International Medical Research , 48 (1), 0300060519897194.
• Ziaeian, B., Fonarow, G. C., & Heidenreich, P. A. (2017). Clinical effectiveness of hydralazine–isosorbide dinitrate in African-American patients with heart failure . JACC: Heart Failure , 5 (9), 632-639.

First published on July 14, 2013. 

24 thoughts on “13 Heart Failure Nursing Care Plans”

good explanation

GOOD NDx keep it up`yeah jah bless

Very good work. You’ve always made my work easier

Thank you! :)

Thank you are really helping me

Am a student nurse and this is really helping me a lot

Thanks alot,had a problem with this but now I feel I can do better

A really benefit websites

This notes are lit and helping alot thanks and keep updating especially pharmacology am astudent nurse

A very nice explanation keep it up!

Thanks much. This is a great jobe well done. Be blessed

Thank you Caleb, check out our other nursing care plans and nursing diagnoses !

I wish you would add some patient education information, sometimes it seems like it may be common knowledge, but I’d like to see specifically focused education topics! Please and thank you!

You can check the deficient knowledge nursing diagnosis for this care plan.

This is great!! I am a student nurse, currently working on my unit for Chronic health conditions. This has really helped me a lot.

Thank you! Gina

this site has been very helpful for me in my studies, very grateful.

Thanks so much, I’m a student nurse currently working on my care study and it has really been helpful.

Please,can I also have a detailed pathophysiology of peripartum cardiomyopathy as well as its nursing care plans. Thanks a lot once again.

This is such a comprehensive nursing care plan for heart failure. I appreciate the author. Kudos to you!

Wow!! These are great!! I wish this site had been around when I was in school!! Even now as an NP. These are a wonderful resource to review processes.. don’t know who came up with this site but kudos to you!!!

So much hands on information. Where can we get it as PDF info

This is good and commendable

Under assessment there is a bullet that is becoming more and more difficult to do: Weigh the patient daily in the hospital or at home.

So many patients are living longer and lack the ability to balance on a scale. Wheelchair scales are too expensive. Ankle measurements and abdominal girth may be good substitutes, but I’m having difficulty finding parameters. It’s really important to find an alternative.

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Heart Failure Case Study (45 min)

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What initial nursing assessments need to be performed for Mr. Jones?

• Full set vital signs
• Heart sounds
• Lung Sounds

What diagnostic tests do you anticipate being ordered by the provider?

• Chest X-ray
• 12-lead EKG
• Echocardiogram
• Cardiac Enzymes

Upon further assessment, the patient has crackles bilaterally and tachycardia. A chest X-ray shows cardiomegaly and bilateral pulmonary edema. An ECG revealed atrial fibrillation. His vital signs were as follows:

BP 150/72 mmHg Urine Yellow and Cloudy

HR 102-123 bpm and irregular BUN 17 mg/dL

RR 24-32 bpm Cr 1.2 mg/dL

Temp 37.3°C H/H 11.8 g/dL / 36.2%

Ht 175 cm LDH 705 U/L

Wt 79 kg ** BNP 843 pg/mL

Mr. Jones was admitted to the cardiac telemetry unit.

Mr. Jones states that this weight is approximately 3 kg more than it was 3 days ago.

What is the significance of Mr. Jones' weight gain?

• 1 kg weight gain is equal to 1 liter of weight gain. This means Mr. Jones has gained 3 liters of fluid (as volume excess) in just 3 days.
• This likely means that there is a new onset or exacerbation of heart failure

What medications do you anticipate the provider ordering for Mr. Jones? Why?

• Diuretics – he is volume overloaded and it is affected his lungs. Diuretics can help relieve fluid retention by promoting excretion of water from the kidneys.
• Beta-Blockers – his blood pressure is high and his heart rate is fast. The beta-blocker can help slow this down and relieve some of the workload of his heart

About three hours after admission to the telemetry unit, Mr. Jones’s skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze.  His SpO 2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm.

What nursing interventions should you perform right away for Mr. Jones?

• Place into High Fowler’s position 
• Apply oxygen
• Administer any PRN medications available for blood pressure (like hydralazine or metoprolol) if criteria are met
• Notify the provider

Describe what is happening to Mr. Jones physiologically.

• Because his heart cannot pump blood efficiently to the body, the blood is backing up into the lungs. This causes pulmonary edema. His pulmonary edema is so severe that he is struggling to breathe and struggling to oxygenate appropriately.
• His heart is trying to work extra hard to compensate for the low cardiac output, that’s why his blood pressure and heart rate are so elevated. This is perpetuated by the RAAS.
• We also see that his kidneys are not being perfused as his urine output has decreased

What medications should be given to decrease Mr. Jones’s preload? Improve his contractility? Decrease his afterload?

• Preload – diuretics (furosemide, bumetanide, spironolactione), ACE inhibitors (captopril, enalapril), ARB’s (losartan, valsartan), ARNI’s (sacubitril/valsartan)
• Contractility – Inotropes (dobutamine), cardiac glycosides (digoxin)
• Afterload – Beta Blockers (metoprolol, carvedilol), vasodilators (hydralazine, nitrates)

What is the expected outcome of administration of Furosemide? Digoxin?

• Furosemide – should see increase in urine output and decrease in respiratory symptoms – may also see a decrease in any peripheral edema
• Digoxin – decrease heart rate and increase the force of contraction – should see evidence of improved peripheral perfusion.

Melander, S. (2004). Case studies in critical care nursing: A guide for application and review, 3 rd ed. Philadelphia, PA: Saunders Elsevier.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
• 7 Questions
• 5 Questions
• 4 Questions

GI/GU Nursing Case Studies

• 2 Questions
• 8 Questions

Obstetrics Nursing Case Studies

Respiratory nursing case studies.

• 10 Questions

Pediatrics Nursing Case Studies

• 3 Questions
• 12 Questions

Neuro Nursing Case Studies

Mental health nursing case studies.

• 9 Questions

Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.

Heart Failure (CHF): Nursing Diagnoses, Care Plans, Assessment & Interventions

Heart failure (HF) , sometimes referred to as Congestive Heart Failure (CHF) , occurs when the heart can’t supply blood effectively to the rest of the body . The left ventricle of the heart is larger and is responsible for most of the pumping action. In left-sided HF , the left ventricle either loses its contractility, so it can’t pump normally, or the ventricle becomes stiff and cannot relax and fill with blood properly between each beat.

Left-sided HF often leads to right-sided heart failure. In right-sided HF , if the right ventricle can’t pump properly, blood backs up in the veins, which leads to congestive heart failure (CHF). If the heart isn’t pumping blood effectively to the body, all organ systems will suffer.

In this article:

• Nursing Process
• Review of Health History
• Physical Assessment
• Diagnostic Procedures
• Nursing Interventions
• Activity Intolerance
• Decreased Cardiac Output
• Decreased Cardiac Tissue Perfusion
• Excess Fluid Volume
• Impaired Gas Exchange
• Ineffective Health Maintenance
• Risk for Unstable Blood Pressure

Nurses play a pivotal role not only in treating patients with heart failure but educating them on lifestyle modifications to prevent disease progression or complications.

The nurse must understand the mechanism of the heart and the pathophysiology of HF in order to effectively treat patients, monitor for impending changes, and prevent worsening effects on other body systems.

Nursing Assessment

The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section we will cover subjective and objective data related to heart failure.

1. Assess the patient’s general symptoms. Record the patient’s complaints and general symptoms, such as:

• Dyspnea on exertion  
• Orthopnea  
• Fatigue /weakness 
• Edema in lower extremities  
• Tachycardia   
• Irregular heartbeat  
• Exercise intolerance 
• Persistent cough  
• Wheezing  
• Abdominal swelling 
• Rapid weight gain  
• Lack of appetite  
• Decreased alertness  

2. Investigate the underlying cause. Heart failure typically occurs due to something else (i.e., another condition/disease or possibly a medication) causing damage to the heart muscle. Conditions that could potentially damage the heart and lead to heart failure include: 

• Coronary artery disease
• Myocardial infarction
• Hypertension
• Heart valve disease
• Myocarditis
• Congenital heart defects
• Cardiac arrhythmias
• Other long-term, chronic conditions that are poorly managed (such as diabetes mellitus , HIV , hyperthyroidism, or hypothyroidism )

3. Identify the stage of heart failure. Heart failure classification is used to denote the severity of symptoms.

Stages of Heart Failure:

• Class I: No limitation to physical activity.
• Class II: Activities of daily living can be completed without difficulty; however, exertion causes shortness of breath and some fatigue.
• Class III: Difficulty completing activities of daily living without fatigue, palpitations, or dyspnea.
• Class IV: Shortness of breath occurs at rest.

4. Know the patient’s risk.

Non-modifiable risk factors:

• Age: The heart can become stiff and frail with advanced age. The risk of heart failure is increased in people over 65. Elderly patients are also more prone to various health issues that cause heart failure.
• Gender: Heart failure is twice as likely to occur in men.
• Family history of ischemic heart disease: There is a high risk if a close female relative (mother or sister) had heart disease before age 65 or if a close male relative (father or brother) had it before age 55.
• Race/ethnicity: Heart failure is more common in African-Americans and Latinos than in Caucasian people.

Modifiable risk factors:

• Hypertension: Uncontrolled high blood pressure can result in stiffening and rigid arteries. Coronary artery constriction may impair blood flow.
• Hyperlipidemia/hypercholesterolemia/coronary artery disease: Increased levels of low-density lipoprotein (LDL) or decreasing levels of high-density lipoprotein (HDL) in the blood can increase the risk of atherosclerosis, narrowing the blood vessels.
• Diabetes or insulin resistance: Hardening of the blood arteries and accumulating fatty plaque are effects of diabetes or insulin resistance.
• Heart valve disease: If the heart valves are impaired, the heart must work harder to pump blood throughout the body, which can lead to heart failure.
• Tobacco use: Smoking accelerates the buildup of plaque in blood vessels. Smokers experience heart failure at a rate twice that of non-smokers.
• Obesity: Obesity increases the risk of high blood pressure, raised blood cholesterol, and diabetes. All are risk factors for heart failure.
• Physical inactivity: Those who are physically inactive are almost two times more likely to acquire heart disease than those who are active.
• Diet: A diet high in fatty, processed foods, high-sodium, or sugary foods increases the risk of obesity and chronic diseases that can lead to heart failure.  
• Stress: Blood vessels constrict as inflammatory levels rise under stress. Excessive stress hormones secreted can lead to heart failure.
• Alcohol use: Alcohol impairs the heart muscle and alters blood clot formation, resulting in the occlusion of blood vessels.
• Lack of sleep: Stress levels rise with insufficient sleep and cause blood vessels to constrict.
• Urinary tract infections
• Endocarditis

5. Review the patient’s treatment record. Medications and past vascular surgery compromise artery integrity. These medications include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Diabetes medications rosiglitazone (Avandia) and pioglitazone (Actos) 
• Antihypertensive medications
• Blood disorders
• Irregular or abnormal heartbeats
• Nervous system disorders
• Mental health issues
• Lung and urinary issues
• Inflammatory diseases

1. Assess the vital signs. Vital indicators, particularly pulse rate and blood pressure, are anticipated to rise or change due to the heart’s reduced oxygenated blood supply. Monitor Spo2 for changes in oxygen saturation that signal deteriorating perfusion.

2. Systemic assessment approach:

• Neck: distended jugular veins 
• CNS: decreased alertness
• Cardiovascular: tachycardia, chest pain, abnormal heart sounds (pathological S3) upon auscultation, arrhythmias
• Circulatory: decreased peripheral pulses, narrow pulse pressure (less than 25 mmHg caused by reduced cardiac output)
• Respiratory: dyspnea on exertion or at rest, tachypnea, orthopnea, persistent or nocturnal cough, crackles or rhonchi in the lung bases upon auscultation
• Gastrointestinal: nausea and vomiting, lack of appetite, abdominal swelling from hepatic congestion and ascites
• Lymphatic: edema in the lower extremities
• Musculoskeletal: neck, arm, back, jaw, and upper body pain, fatigue, muscle weakness, activity intolerance, rapid weight gain from fluid
• Integumentary: cyanotic and pale skin and excessive sweating

1. Obtain ECG. ECG findings in heart failure are characterized by P wave changes resulting in left atrial hypertrophy (enlargement).

2. Analyze BNP lab results. As heart failure occurs, the heart releases B-type natriuretic peptide (BNP) in the blood, causing an elevation in the blood test. 

3. Investigate other blood tests.

• Complete blood count with differential indicates the presence of infection (WBC), blood coagulation (platelets), and anemia (low RBC levels).
• Cholesterol levels show a risk for coronary artery disease (a risk factor for heart failure).
• Thyroid levels reflect disturbed thyroid hormones that can cause arrhythmias.

4. Review chest X-ray results. Chest X-ray shows any changes in the size of the heart. It also reflects fluid accumulation around the heart and lungs.

5. Prepare the patient for an echocardiogram. An echocardiogram assesses the heart’s structure. This test is used to identify ejection fraction (EF) , a percentage that measures how well the ventricles pump blood. 

• An EF of 55-70% is normal
• 40-54% is slightly below normal and may not produce symptoms
• 35-39% is considered mild heart failure
• EF less than 35% is moderate to severe heart failure

6. Investigate further.

• Exercise treadmill test benefits a patient who is physically capable of exercising and has a normal resting ECG.
• Nuclear stress test shows images of blood flow to the heart muscle using an IV radioactive tracer dye. This is combined with exercise or medication to stimulate the heart rate.
• Stress imaging is for patients who had revascularization, with challenging ECGs to read, or are physically unable to exercise.
• Cardiac CT scan displays calcium deposits and cardiac artery blockages.
• Cardiac catheterization reveals any obstructed cardiac arteries or the presence of coronary artery disease.
• CT coronary angiogram is comparable to a cardiac CT scan but creates a more detailed image using dye (contrast).
• Myocardial biopsy investigates other heart diseases that can cause heart failure.

Nursing interventions and care are essential for the patients recovery. In the following section you’ll learn more about possible nursing interventions for a patient with heart failure.

Promote Perfusion

1. Relax the blood vessels. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) improve blood flow by relaxing the blood vessels. It also lowers blood pressure and cardiac muscle strain.

2. Lower the heart rate and pressure. Administer beta-blockers to reduce the heart rate and blood pressure, which can improve heart function.

3. Induce diuresis. Diuretics cause an increase in urination to remove excess fluid from the body.

4. Consider potassium-sparing diuretics. Aldosterone antagonists are potassium-sparing diuretics that help treat systolic heart failure. It removes the excess fluid in the heart and body.

5. Strengthen the heart contraction.

• Inotropes are typically given IV while hospitalized. These are designed to increase the effectiveness of the heart pumping and maintain blood pressure.
• Digoxin increases the strength of the heart’s contractions. Monitor closely for digoxin toxicity through lab testing.

6. Treat the underlying condition.

• Coronary artery bypass graft surgery (CABG) builds an additional pathway for blood in the heart. The blocked or constricted coronary artery is bypassed using an artery from another part of the body, such as the leg.
• Heart valve repair or replacement fixes or replaces the defective heart valve causing heart failure. 
• Cardiac resynchronization therapy (CRT) uses a biventricular pacemaker to correct electrical signals in the heart that causes arrhythmias.
• Ventricular assist devices (VADs) are mechanical pumps that improve heart contraction and pumping in heart failure.
• Heart transplant is recommended for patients with severe heart failure when treatments are no longer effective.

Cardiac Rehabilitation

1. Collaborate with the team. Patients will work with cardiologists, cardiac rehab nurse specialists, dieticians, social workers, and physical and occupational therapists to meet their health needs.

2. Improve activity tolerance. Following surgery or a procedure for heart failure, recovery will take time. Cardiac rehab will slowly introduce exercises to strengthen the heart.

3. Strengthen the patient’s health. Cardiac rehab enhances the patient’s health and quality of life by supporting the patient in restoring strength and preventing HF recurrence and complications.

Reduce the Risk of Complications

1. Regulate the heart rhythm. Implantable cardioverter-defibrillators (ICDs) are devices that prevent heart failure complications. ICD tracks the heart rhythm and keeps the heart rate regular if an arrhythmia occurs.

2. Repeat the importance of lifestyle modifications.  Adopting lifestyle adjustments can reduce heart failure symptoms and keep the condition from getting worse.

• Regular exercise
• Heart-healthy diets
• Smoking cessation
• Avoiding secondhand smoke
• Stress management
• Vaccinations
• Limiting alcohol consumption
• Restful sleep

3. Advise on activity.  Aerobic exercise regularly improves heart function in persons with heart disease. Physical activity may be difficult or impossible for patients with severe HF. Advise the patient to go for five to ten minutes at a moderate pace and aim to add one or two minutes daily as they can. 

4. Keep a healthy weight. Being overweight can cause fatty deposits to build up in the arteries. Advise the patient to limit saturated or trans fat. Blood pressure, cholesterol, and metabolic activity all improve with weight loss. 

5. Promote patient adherence to treatment. Treatment adherence promotes continuity of care and patient-centered care. Increased patient adherence leads to more efficient HF treatment and prevention of complications.

6. Decrease stress. Stress raises blood pressure and heart rate. Because the inflammatory response is activated, blood vessels constrict, increasing the risk of HF. Guided imagery, yoga, deep breathing exercises, muscle relaxation, meditation, and getting adequate sleep are examples of stress reduction techniques.

7. Prevent fluid accumulation. Monitor for any swelling in the lower extremities, which may indicate the presence of edema or fluid accumulation. Instruct on contacting their healthcare team if weight gain of more than 2.5 lbs overnight or 5 lbs in a week is observed. Also, limit sodium (salt) intake to prevent water retention. Fluid accumulation can increase the heart’s workload. 

8. Teach the patient when to seek medical attention. HF signs and symptoms that are a cause for concern are:

• Sudden weight gain
• Fainting (syncope)
• Sudden productive cough with white or pink, foamy secretions

9. Follow up with the cardiologist. Visits to a cardiologist and regular examinations, such as blood tests and echocardiograms, will aid in monitoring the disease process. Patients with HF are advised to visit their cardiologist every three-six months or as recommended.

10. Emphasize the use of medical identification. The emergency responders can be alerted about the patient’s history of HF by a medical identity bracelet, necklace, or ID tag. This can be helpful, especially for patients who are living alone.

Nursing Care Plans

Once the nurse identifies nursing diagnoses for heart failure, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for heart failure.

Activity intolerance is a common manifestation and nursing diagnosis related to HF that can lead to worsening health conditions and physical deconditioning.

Nursing Diagnosis: Activity Intolerance

Related to:

• Imbalance between oxygen supply and demand 
• Weakness/deconditioning 
• Sedentary lifestyle 

As evidenced by:

• Fatigue 
• Dyspnea 
• Immobility  
• Vital sign changes in response to activity 
• Chest pain on exertion 
• Diaphoresis 

Expected outcomes:

• Patient will perform activities within their limitations so as not to stress cardiac workload.
• Patient will alternate between work and rest periods to complete ADLs.
• Patient will demonstrate vital signs and heart rhythm within normal limits during activity.

Assessment:

1. Observe cardiopulmonary response to activity. The nurse can monitor the patient’s heart rate, oxygen saturation, and cardiac rhythm during activity. A rise or drop in blood pressure, tachycardia, or EKG changes can signify overexertion and help plan appropriate interventions.

2. Assess the patient’s perspective. Assess the patient’s understanding of their condition and their perceived activity limitations. The goal is to ensure the patient is not overexerting themselves but also feels motivated to make progress with their activity tolerance and maintain independence.

3. Assess the degree of debility. Interventions can be tailored to the severity of the patient’s symptoms. Assess the level of fatigue, weakness, and dyspnea in relation to activity and length of exertion. The nurse may need to assist with ADLs or adjust the activities the patient can undertake for their safety .

Interventions:

1. Provide a calm environment. Dyspnea from HF can result in anxiety and restlessness. Provide the patient with a cool, dimly lit space free from clutter and stimulation. Assist the patient in taking slow, controlled breaths and provide emotional support so they feel in control.

2. Encourage participation. Even a patient with chronic HF and severe activity intolerance can assist with care to some extent. Provide toiletries at the bedside so the patient can brush their teeth or comb their hair. Have the patient assist with turning themselves in bed. A patient who becomes immobile from a sedentary lifestyle is at an increased risk for other complications such as skin breakdown, deep vein thrombosis (DVT) , and pneumonia.

3. Teach methods to conserve energy. Group tasks together, sit when possible when performing ADLs, plan rest periods, promote restful sleep, do not rush activities, and avoid activities in hot or cold temperatures.

4. Recommend cardiac rehabilitation. This is a medically supervised outpatient program that teaches a patient with a cardiac history how to reduce their risk of heart problems through exercise, heart-healthy diets, stress reduction , and management of chronic conditions. This is a team-based approach working with providers, nurses who specialize in cardiac care, PT and OT, and dieticians.

A decline in stroke volume from a loss of cardiac contractility or muscle compliance results in reduced filling or ejection of the ventricles. This reduced output decreases blood flow to other organs.

Nursing Diagnosis: Decreased Cardiac Output

• Altered heart rate/rhythm 
• Altered contractility 
• Structural changes (aneurysm, rupture) 
• Increased heart rate (palpitations) 
• Dysrhythmias 
• Shortness of breath 
• Anxiety  
• Orthopnea 
• Jugular vein distention; edema 
• Central venous pressure changes 
• Murmurs 
• Decreased peripheral pulses 
• Decreased urine output 
• Skin pallor, mottling, or cyanosis 
• Patient will display hemodynamic stability with vital signs, cardiac output, and renal perfusion within normal limits.
• Patient will participate in activities that reduce the workload of the heart.
• Patient will report an absence of chest pain or shortness of breath.

1. Assess vital signs, cardiac rhythm, and hemodynamic measurements. HF patients benefit from continuous cardiac monitoring via telemetry. The nurse can then act quickly if a dysrhythmia is observed. Blood pressure, pulse rate, and oxygen saturation should also be assessed regularly for changes. Unstable patients may need hemodynamic monitoring to maintain adequate perfusion.

2. Monitor skin and pulses. Poor cardiac output will result in decreased tissue perfusion . The nurse may observe skin mottling, pallor, or cyanosis. The skin may also feel cool or clammy. Along with these outward changes, peripheral pulses may be weak or irregular due to the lack of circulating blood volume.

3. Monitor mental status changes. HF can have long-term mental effects on the brain leading to poor memory and impaired cognition. The nurse can monitor for subtle changes or a decline in baseline presentation such as acute confusion or altered alertness.

1. Apply oxygen. Patients with low oxygen saturation may need supplemental oxygen due to the heart’s inability to pump oxygen-rich blood to the body. Patients with chronic HF may require oxygen therapy at home.

2. Administer medications. Vasodilators open arteries and veins to allow for decreased vascular resistance, increasing cardiac output and reducing ventricular workload. Morphine and anti-anxiety medications help with relaxing and calming the patient which can reduce cardiac workload. Angiotensin receptor blockers (ARBs) lower blood pressure and make pumping blood easier for the heart.

3. Instruct on ways to reduce the workload of the heart. Depending on the severity of the patient’s HF, they may need to modify daily activities. They may need assistance with ADLs, plenty of rest periods, and reduced exercise regimens.

4. Educate on risk factors and lifestyle modifications. Patients who are not yet diagnosed with HF or only have mild HF should be educated on prevention. Educate patients on risk factors such as hypertension, diabetes, atherosclerosis, and myocardial infarction that increase the risk of developing heart failure. Modifiable risk factors like smoking, obesity , sedentary lifestyle, and diets high in fat also increase the risk.

Decreased cardiac tissue perfusion associated with heart failure can be caused by insufficient blood flow resulting from impaired cardiac function.

Nursing Diagnosis: Decreased Cardiac Tissue Perfusion

• Structural impairment of the heart
• Malfunctions of the heart structures
• Difficulty of the heart muscle to pump
• Increased exertion in workload
• Inadequate blood supply to the heart
• Inability to contract and relax effectively
• Erratic signals causing chaotic or irregular heart contraction
• Decreased cardiac output
• Decreased blood pressure (hypotension)
• Decreased peripheral pulses
• Increased central venous pressure (CVP)
• Increased pulmonary artery pressure (PAP)
• Tachycardia
• Dysrhythmias
• Ejection fraction less than 40%
• Decreased oxygen saturation
• Presence of abnormal S3 and S4 heart sounds upon auscultation
• Patient will manifest pulse rate and rhythm within normal limits.
• Patient will demonstrate ejection fraction >40%.
• Patient will maintain palpable peripheral pulses.

1. Auscultate the apex of the heart. Determine if an abnormal heart sound S3 or S4 can be detected by auscultating the left lower sternal border. Children and athletes may naturally produce an S3 heart sound, but it is an abnormal finding in older adults and those with heart failure. Blood ejecting into a rigid ventricle causes the S4 heart sound.

2. Assist in myocardial perfusion test. Myocardial perfusion imaging (nuclear stress test) demonstrates how efficiently blood flows through the heart muscle. Additionally, it displays how efficiently the heart is pumping.

3. Check the BNP or NT-proBNP. B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) diagnoses heart failure (HF). It also supports the diagnosis of acutely decompensated HF in hospitalized patients or those treated in emergency rooms.

4. Obtain EKG. EKG can help rule out HF with a high sensitivity but low specificity. It can reveal the cause (such as a history of previous MI) and offer therapeutic indications (such as anticoagulation for atrial fibrillation).

5. Assist in TEE. Transthoracic echocardiography (TEE) can be useful in determining ejection fraction, left-atrial pressure, and cardiac output.

6. Prepare for a left heart catheterization or coronary angiography. Left-heart catheterization or coronary angiography is done to identify blockages or abnormalities with blood vessels in the heart to guide interventions.

1. Set the goal with the patient. Therapy aims to increase survival and symptoms, shorten hospital stays and avoid HF readmission, minimize morbidity, prevent HF-related organ damage, and suppress symptoms in patients with asymptomatic heart failure.

2. Administer medications as ordered. The following medications are included in the pharmacologic treatment of HF:

• Angiotensin system blockers (ACE inhibitors, ARBs, or ARNIs)
• Hydralazine with nitrate as an alternative if angiotensin system blockers are not tolerable
• Beta-blockers

3. Instruct on lifestyle modifications. Behavioral and lifestyle modifications include the following:

• Dietary and nutritional consultation
• Limit sodium to 2 to 3 g/day
• Fluid restriction to 2 L/day 
• Weight monitoring
• Aerobic exercise training 
• Control of existing risk factors (such as DM and lipid disorders)
• Smoking/alcohol/ illicit drug use cessation

4. Consider device therapy. Device therapies include cardiac resynchronization treatment (CRT) and implanted cardioverter-defibrillators (ICD). Patients should receive ACE inhibitors/ARB plus beta-blockers for at least three months prior to surgery. 

5. Anticipate the possibility of surgery. Heart transplantation, heart valve replacement, catheter ablation, and more are procedures to remodel, repair, or replace all or part of the heart’s function in treating HF. Surgery is often considered when medications aren’t effective.

Heart failure results in poor perfusion of the kidneys. If the kidneys cannot excrete sodium, water retention will occur and accumulate in tissues leading to fluid overload.

Nursing Diagnosis: Excess Fluid Volume

• Fluid intake or sodium intake 
• Reduced glomerular filtration rate  
• Increased secretion of antidiuretic hormone 
• Weight gain 
• Edema in extremities 
• Jugular vein distention 
• Adventitious breath sounds (crackles, rales) 
• High blood pressure 
• Oliguria 
• Tachycardia 
• Pulmonary congestion 
• Cough 
• S3 heart sound 
• Patient will demonstrate stable fluid volume through balanced intake and output, normal baseline weight, and no peripheral edema.
• Patient will verbalize signs and symptoms of fluid overload and when to seek help.
• Patient will verbalize dietary recommendations and fluid restrictions to maintain.

1. Assess for peripheral edema, anasarca, and JVD. Signs of fluid retention include edema in the lower legs and feet which is often pitting or generalized edema to the entire body known as anasarca. The most reliable sign indicating fluid overload is jugular vein distention (JVD).

2. Monitor breath and heart sounds. Patients with congestive heart failure (CHF) will present with shortness of breath and may have a cough with blood-tinged sputum due to pulmonary congestion. Upon assessment, the nurse will likely hear “wet” breath sounds (crackles). An S3 gallop signifies significant heart failure.

3. Monitor urine output and strict I&Os. Strict documentation of intake and output is required to monitor hydration and prevent worsening fluid overload. The nurse should record intake from oral and IV sources, maintain adherence to fluid restrictions, and assess urine output and characteristics. This is especially important if the patient is on diuretic therapy.

1. Maintain upright position. Semi-Fowlers or Fowler’s positioning will help the patient breathe easier and maintain comfort. They may require extra pillows or need to sleep in a reclining chair at home.

2. Administer diuretics. Diuretics are often prescribed as they rid the body of excess fluid which will decrease edema and dyspnea. Diuretics can be given by mouth or IV and must be monitored closely as they increase urination, decrease blood pressure, and decrease potassium.

3. Instruct on sodium and fluid restrictions. Diet education may include decreasing sodium and restricting fluids and will be directed by a provider. Patients should not use table salt or add salt to foods and should be aware of sodium contents in frozen or canned food. If a fluid restriction is ordered, the patient can track this by using a large pitcher that is their daily amount of fluid and drinking from it throughout the day. Ensure the patient understands their restriction includes all sources of fluid: soups, jello, and ice cream.

4. Teach how to monitor for fluid volume overload. Educate patients at discharge on signs of fluid retention. They should weigh themselves daily, using the same scale and at the same time each day. If a weight gain of 2 lbs in 24 hours or 5 lbs in a week is observed, they should call their doctor. Observed swelling to ankles or feet as well as an increase in dyspnea also requires assessment.

Inadequate blood flow results in decreased oxygenation and perfusion to tissues and organs. Heart failure itself is a related factor, but complications such as excess fluid can further impair gas exchange.

Nursing Diagnosis: Impaired Gas Exchange

• Ventilation perfusion imbalance related to altered blood flow 
• Changes to the alveolar-capillary membrane 
• Pulmonary congestion due to fluid retention 
• Changes in mental status 
• Restlessness 
• Anxiety 
• Abnormal ABGs 
• Changes in respiratory rate, depth, or rhythm 
• Patient will maintain ventilation and perfusion as evidenced by ABGs within normal limits.
• Patient will display improvement in ventilation by oxygen saturation above 95%.
• Patient will participate in ambulation and ADLs as allowed by respiratory ability.

1. Auscultate breath sounds. The patient may experience crackles, wheezes, or diminished breath sounds related to excess fluid in the lungs. Monitor closely for acute respiratory changes.

2. Monitor pulse oximetry. Abnormal oxygen saturation levels are a sign of hypoxemia, a lack of oxygen in the blood. This requires oxygen therapy and the underlying cause should be investigated and treated.

3. Monitor arterial blood gases (ABGs). ABGs measure the amount of oxygen and carbon dioxide in the blood. Abnormal or worsening ABGs indicate that the lungs are not ventilating or removing CO2 adequately.

1. Educate on coughing and deep breathing exercises. Clearing the airway and expanding the lungs will assist in promoting oxygenation.

2. Change positions frequently. Movement also assists with the drainage of secretions which can decrease the risk of complications such as atelectasis and/or pneumonia. If the patient is able to ambulate, this should be encouraged multiple times per day.

3. Maintain semi-Fowler’s position. Keeping the head of the bed elevated maintains an open airway. This can also be based on the patient’s comfort as some cannot tolerate high-Fowler’s positioning. If the patient is able to sit in a chair this is recommended.

4. Administer supplemental oxygen as needed. Apply oxygen per provider orders and to maintain the oxygenation of the patient. Patients may need oxygen titrated up or down or may require more significant interventions such as BiPap or mechanical ventilation.

5. Administer medications as ordered. If the impaired gas exchange is in relation to excess fluid volume, medications such as diuretics may be required to treat the underlying cause.

Poor patient understanding or management of their condition can result in worsening symptoms and outcomes.

Nursing Diagnosis: Ineffective Health Maintenance

• Lack of understanding of heart failure and prognosis 
• Difficulty in following recommended treatment plan 
• Poor motivation to make lifestyle changes 
• Insufficient resources (access to cardiologist, finances) 
• Lack of support from family to encourage or monitor condition 
• Demonstrates a lack of knowledge of heart failure 
• Continues with inappropriate diet or behaviors despite education 
• Inconsistent with keeping appointments, taking medications, etc. 
• Patient will seek out information to prevent worsening heart failure.
• Patient will identify (3) lifestyle modifications to improve heart failure.
• Patient will take responsibility for their health outcomes by identifying areas for improvement.

1. Assess the level of understanding of the disease process. Determine the patient’s present knowledge of risk factors, symptoms, treatments, and goals in order to tailor teaching to meet their needs.

2. Assess support system. Management of chronic conditions can be very challenging for patients and having a strong support system can assist in better adherence to the treatment plan.

1. Educate on normal heart function compared to the patient’s current heart function. Understanding the disease process can help the patient understand the goals of treatment and improve adherence. Explaining results of testing, such as the EF, or reviewing the HF classification system helps them feel more involved in their care.

2. Reinforce the rationale of treatments. Furthermore, patients may not grasp the reasoning for certain treatments such as fluid restrictions, weighing themselves daily, or the importance of medications. Explain in simple terms and provide written education if appropriate.

3. Educate on the importance and benefits of regular exercise. This will assist with maintaining muscle strength and organ function to strengthen the heart. Ensure exercise programs are safe for the patient and cleared by their provider.

4. Review medications. Thorough medication reconciliation and review is required before discharge or after each provider visit. The nurse should review changes and instruct on frequencies, side effects, and any considerations with each medication.

Risk for unstable blood pressure (BP) associated with heart failure can be caused by impaired structure and function of the heart muscle to pump blood effectively throughout the body.

Nursing Diagnosis: Risk for Unstable Blood Pressure

• Conditions that compromise the blood supply

A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.

• Patient will maintain blood pressure within normal limits.
• Patient will not experience hypotension with activity.
• Patient will maintain strict adherence to antihypertensive medications as ordered.

1. Closely assess the patient’s blood pressure. Heart attack and stroke can result from high systolic and diastolic blood pressure. Advise treating hypertension in heart failure with decreased ejection fraction. The target blood pressure is 130/80 mmHg.

2. Obtain blood samples for lab tests. The following blood tests determine the risk for unstable blood pressure in patients with heart failure:

• Blood urea nitrogen and serum creatinine
• Electrolyte levels
• Thyroid function
• Cholesterol (lipid) levels
• Blood glucose levels
• Liver function

3. Review the patient’s current treatment. Medications and herbal remedies aggravate or induce heart failure because they affect the blood pressure and heart muscles’ ability to pump blood and interact with other treatments and medications for heart failure. Examples of medications include:

• Spironolactone, angiotensin-converting enzyme (ACE) inhibitor, and furosemide can lead to electrolyte imbalances and renal failure
• Opioids and stimulants disturb the natural balance of certain neurotransmitters in the body and brain (catecholamines)
• Ashwagandha, blue cohosh, and Yohimbe are herbs sold in the United States that can cause cardiac toxicity

4. Identify underlying conditions. Systemic diseases, cardiac disorders, and some genetic defects can result in heart failure. The most prevalent underlying causes of heart failure are coronary artery disease, hypertension, and a previous heart attack.

1. Treat the underlying condition. Treatment of heart failure starts with prevention by reducing the risk factors. Patients should work to manage their blood pressure through exercise, weight loss, diet, medications, and smoking cessation.

2. Alert the patient when to seek emergency care. Symptoms of hypertension or hypotension include:

• A rapid heartbeat 
• Dizziness or fainting
• Profuse sweating
• Blurred vision

3. Instruct on how to take an accurate blood pressure reading. If the patient is monitoring their blood pressure at home, ensure they adhere to the following:

• Try to take the blood pressure at the same times each day
• Rest for 5-10 minutes to allow the blood pressure to return to baseline
• Do not cross your legs or ankles while taking a blood pressure
• Do not talk while taking a blood pressure

Ensure the patient and/or family member are using the correct size cuff and placing it correctly on the arm.

4. Advise the patient to keep BP logs. Heart failure (HF) patients’ usual clinical practice includes checking their blood pressure regularly. It is generally recognized that increased BP predicts cardiovascular risk. Advise the patient to keep accurate records to allow the healthcare team to monitor the effectiveness of treatment.

• Ackley, B.J., Ladwig, G.B., Flynn Makic M.B., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook: An evidence-based guide to planning care (12th edition). Mosby.
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• Blumenthal, R. & Jones, S. (2021). Congestive heart failure: Prevention, treatment, and research. https://www.hopkinsmedicine.org/health/conditions-and-diseases/congestive-heart-failure-prevention-treatment-and-research
• Brown AC. Heart Toxicity Related to Herbs and Dietary Supplements: Online Table of Case Reports. Part 4 of 5. J Diet Suppl. 2018 Jul 4;15(4):516-555. doi: 10.1080/19390211.2017.1356418. Epub 2017 Oct 5. PMID: 28981338.
• Cardiac Rehab for Heart Failure. (2017, May 31). American Heart Association. Retrieved January 26, 2022, from https://www.heart.org/en/health-topics/heart-failure/treatment-options-for-heart-failure/cardiac-rehab-for-heart-failure
• Centers for Disease Control and Prevention. (2022, October 14). Heart failure. Retrieved February 2023, from https://www.cdc.gov/heartdisease/heart_failure.htm
• Cleveland Clinic. (2022, January 21). Heart failure: Common symptoms, causes and treatment. Retrieved March 2023, from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure
• Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
• Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th edition). F.A. Davis Company.
• Dumitru, I., & Sharma, G. K. (2021, October 27). Heart Failure Treatment & Management: Approach Considerations, Nonpharmacologic Therapy, Pharmacologic Therapy. Medscape Reference. Retrieved January 26, 2022, from https://emedicine.medscape.com/article/163062-treatment
• Heart failure – Symptoms and causes. (2021, December 10). Mayo Clinic. Retrieved January 26, 2022, from https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142
• Heart Failure: Types, Symptoms, Causes & Treatments. (n.d.). Cleveland Clinic. Retrieved January 26, 2022, from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure
• Heckman, G. A., Patterson, C. J., Demers, C., St Onge, J., Turpie, I. D., & McKelvie, R. S. (2007). Heart failure and cognitive impairment: challenges and opportunities. Clinical interventions in aging, 2(2), 209–218.
• Mayo Clinic. (2021, December 10). Heart failure – Diagnosis and treatment – Mayo Clinic. Retrieved March 2023, from https://www.mayoclinic.org/diseases-conditions/heart-failure/diagnosis-treatment/drc-20373148
• Micaela, I. (2020, June 25). Heart failure – fluids and diuretics. MedlinePlus. Retrieved January 26, 2022, from https://medlineplus.gov/ency/patientinstructions/000112.htm
• National Center for Biotechnology Information. (2022, April 30). Heart failure and ejection fraction – StatPearls – NCBI bookshelf. Retrieved March 2023, from https://www.ncbi.nlm.nih.gov/books/NBK553115/
• Pellicori, P., Kaur, K., & Clark, A. L. (2015). Fluid Management in Patients with Chronic Heart Failure. Cardiac failure review, 1(2), 90–95. https://doi.org/10.15420/cfr.2015.1.2.90
• The Trustees of the University of Pennsylvania. (2020, August 27). Avoid these foods if you have heart failure – Penn medicine. Penn Medicine. Retrieved March 2023, from https://www.pennmedicine.org/updates/blogs/heart-and-vascular-blog/2020/august/avoid-these-foods-if-you-have-heart-failure
• Types of Heart Failure. (2017, May 31). American Heart Association. Retrieved January 26, 2022, from https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/types-of-heart-failure
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Outcomes for patients with congestive heart failure in a nursing case management model

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• 1 Capstone College of Nursing, University of Alabama, Tuscaloosa 35487-0358, USA.
• PMID: 10067547

Congestive heart failure is a leading cause of hospital admissions, costing an estimated $7 billion in 1990. Hospital-based nursing case management has been used to reduce costs of care while maintaining quality of care. This study describes the outcomes for 50 patients with congestive heart failure in a hospital-based nursing care management model, providing general outcomes, physiologic status, physical functioning, health knowledge, and family caregiver status. The number of medications was the only predictor of length of stay using regression analysis.

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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

[case management for patients with congestive heart failure under ambulatory care: a critical review].

Review published: 2004 .

Bibliographic details: Gensichen J, Beyer M, Kuver C, Wang H, Gerlach FM.  [Case management for patients with congestive heart failure under ambulatory care: a critical review]. [Case Management fur Patienten mit Herzinsuffizienz in der ambulanten Versorgung: ein kritischer Review.] Zeitschrift fur Arztliche Fortbildung und Qualitatssicherung 2004; 98(2): 143-154. [ PubMed : 15106496 ]

BACKGROUND: Congestive Heart Failure (CHF) is becoming the most serious cardiac health problem after coronary heart disease (CHD). But at present, service offered to CHF patients are flawed because of the fragmentation and discontinuity of care. Case management (CM) takes responsibility for following up patients, for assessing symptoms and taking action when patients do not adhere to guideline based treatment or fail to improve. This review analyses the evidence of primary care based CM for patients with CHF.

METHODS: Searches in Medline using relevant MeSH terms and hand-searching were applied to identify relevant studies. We selected RCTs and pre-post studies focussing on patient-centred CM in ambulatory settings. A five-level score (simple to complex) was generated to describe interventions and compare results.

RESULTS: 23 of 462 identified studies (16 RCT, 7 others) that fulfilled our selection and quality criteria were included. We classified 15 studies as "complex" CM, i.e. they contained more than three elements of intervention, were strongly integrated with the process of care, involved a specialised nurse, and offered individual patient education. All studies examined the length of hospital stay: costs were investigated in 17, quality of life in 10 and mortality in 7 studies. Studies examining a "complex" CM demonstrated positive effects on mortality and quality of life in the 3-6 months of follow up. Studies with a follow up period of 12 to 18 months showed a reduction of hospital days.

CONCLUSION: Especially "complex" models of CM for patients with CHF can be effective in a primary care setting. CM can prevent the fragmentation and discontinuity of care by strengthening a close contact between patient and health care provider.

• Cite this Page Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. [Case management for patients with congestive heart failure under ambulatory care: a critical review] 2004.

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Chapter 5:  10 Real Cases on Acute Heart Failure Syndrome: Diagnosis, Management, and Follow-Up

Swathi Roy; Gayathri Kamalakkannan

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Case 1: Diagnosis and Management of New-Onset Heart Failure With Reduced Ejection Fraction

A 54-year-old woman presented to the telemetry floor with shortness of breath (SOB) for 4 months that progressed to an extent that she was unable to perform daily activities. She also used 3 pillows to sleep and often woke up from sleep due to difficulty catching her breath. Her medical history included hypertension, dyslipidemia, diabetes mellitus, and history of triple bypass surgery 4 years ago. Her current home medications included aspirin, atorvastatin, amlodipine, and metformin. No significant social or family history was noted. Her vital signs were stable. Physical examination showed bilateral diffuse crackles in lungs, elevated jugular venous pressure, and 2+ pitting lower extremity edema. ECG showed normal sinus rhythm with left ventricular hypertrophy. Chest x-ray showed vascular congestion. Laboratory results showed a pro-B-type natriuretic peptide (pro-BNP) level of 874 pg/mL and troponin level of 0.22 ng/mL. Thyroid panel was normal. An echocardiogram demonstrated systolic dysfunction, mild mitral regurgitation, a dilated left atrium, and an ejection fraction (EF) of 33%. How would you manage this case?

In this case, a patient with known history of coronary artery disease presented with worsening of shortness of breath with lower extremity edema and jugular venous distension along with crackles in the lung. The sign and symptoms along with labs and imaging findings point to diagnosis of heart failure with reduced EF (HFrEF). She should be treated with diuretics and guideline-directed medical therapy for congestive heart failure (CHF). Telemetry monitoring for arrythmia should be performed, especially with structural heart disease. Electrolyte and urine output monitoring should be continued.

In the initial evaluation of patients who present with signs and symptoms of heart failure, pro-BNP level measurement may be used as both a diagnostic and prognostic tool. Based on left ventricular EF (LVEF), heart failure is classified into heart failure with preserved EF (HFpEF) if LVEF is >50%, HFrEF if LVEF is <40%, and heart failure with mid-range EF (HFmEF) if LVEF is 40% to 50%. All patients with symptomatic heart failure should be started on an angiotensin-converting enzyme (ACE) inhibitor (or angiotensin receptor blocker if ACE inhibitor is not tolerated) and β-blocker, as appropriate. In addition, in patients with New York Heart Association functional classes II through IV, an aldosterone antagonist should be prescribed. In African American patients, hydralazine and nitrates should be added. Recent recommendations also recommend starting an angiotensin receptor-neprilysin inhibitor (ARNI) in patients who are symptomatic on ACE inhibitors.

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